Provider Demographics
NPI:1215770508
Name:DAVIS, JESSICA ANNE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNE
Last Name:DAVIS
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 1:104 SECLUDED OAKS CT
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-2804
Mailing Address - Country:US
Mailing Address - Phone:772-971-6751
Mailing Address - Fax:
Practice Address - Street 1:104 SECLUDED OAKS CT
Practice Address - Street 2:
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707-2804
Practice Address - Country:US
Practice Address - Phone:772-971-6751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-14
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND8029133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered