Provider Demographics
NPI:1215085071
Name:GOSS, JERIL ALTMIRE (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:JERIL
Middle Name:ALTMIRE
Last Name:GOSS
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1440
Mailing Address - Country:US
Mailing Address - Phone:814-375-3890
Mailing Address - Fax:814-375-6388
Practice Address - Street 1:145 HOSPITAL AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1462
Practice Address - Country:US
Practice Address - Phone:814-375-3890
Practice Address - Fax:814-375-6388
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN000996133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA09810124OtherBOARD CERTIFICATION - NCBDE
PA710814OtherRDN