Provider Demographics
NPI:1861768913
Name:PAINE, JESSICA J (RDLD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:J
Last Name:PAINE
Suffix:
Gender:F
Credentials:RDLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 N 30TH ST
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-4047
Mailing Address - Country:US
Mailing Address - Phone:270-444-8183
Mailing Address - Fax:270-444-8147
Practice Address - Street 1:619 N 30TH ST
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-4047
Practice Address - Country:US
Practice Address - Phone:270-444-8183
Practice Address - Fax:270-444-8147
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2420133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered