Provider Demographics
NPI:1316674609
Name:PEARSON, XAVIER JACOB LEE (MS, RD, LD, CNSC)
Entity type:Individual
Prefix:MR
First Name:XAVIER
Middle Name:JACOB LEE
Last Name:PEARSON
Suffix:
Gender:M
Credentials:MS, RD, LD, CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:776 W PEARL ST
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-2878
Mailing Address - Country:US
Mailing Address - Phone:417-298-1366
Mailing Address - Fax:
Practice Address - Street 1:1500 N OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-3011
Practice Address - Country:US
Practice Address - Phone:417-328-6462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014031795133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered