Provider Demographics
NPI:1104586783
Name:LEBRON, JESSICA R (MHSN, RD, LDN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:R
Last Name:LEBRON
Suffix:
Gender:F
Credentials:MHSN, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB VILLA CONTESSA
Mailing Address - Street 2:F24 CALLE ARAGON
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00956-2778
Mailing Address - Country:US
Mailing Address - Phone:469-449-3634
Mailing Address - Fax:
Practice Address - Street 1:715 AVE PONCE DE LEON
Practice Address - Street 2:
Practice Address - City:HATO REY
Practice Address - State:PR
Practice Address - Zip Code:00917-5032
Practice Address - Country:US
Practice Address - Phone:787-758-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-23
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR002192133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered