Provider Demographics
NPI:1154421238
Name:SEYMOUR, JESSICA THEOBALD (NUTRITIONIST)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:THEOBALD
Last Name:SEYMOUR
Suffix:
Gender:F
Credentials:NUTRITIONIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 N QUEEN ST
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501-4932
Mailing Address - Country:US
Mailing Address - Phone:252-522-9485
Mailing Address - Fax:
Practice Address - Street 1:324 N QUEEN ST
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-4932
Practice Address - Country:US
Practice Address - Phone:252-522-9485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL001943133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCL001943OtherNUTRITIONIST LICENSE