Provider Demographics
NPI:1548667439
Name:PAGE, JESSICA CHRISTINE (RD, LD)
Entity type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:CHRISTINE
Last Name:PAGE
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1908 MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-5519
Mailing Address - Country:US
Mailing Address - Phone:618-972-6418
Mailing Address - Fax:
Practice Address - Street 1:1908 MEADOW LN
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-5519
Practice Address - Country:US
Practice Address - Phone:618-972-6418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-20
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014037633133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered