Provider Demographics
NPI:1801252580
Name:BETTICK, JESSICA L
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:BETTICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 W SHIRLEY AVE
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:VA
Mailing Address - Zip Code:20186-3008
Mailing Address - Country:US
Mailing Address - Phone:540-347-9220
Mailing Address - Fax:540-347-3869
Practice Address - Street 1:225 OAK SPRINGS DR
Practice Address - Street 2:SUITE 201
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186-2187
Practice Address - Country:US
Practice Address - Phone:540-878-5408
Practice Address - Fax:540-878-5731
Is Sole Proprietor?:No
Enumeration Date:2016-01-11
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI994986OtherCOMMISSION ON DIETETIC REGISTRATION- ACADEMY OF NUTRITION AND DIETETICS