Provider Demographics
NPI:1386078368
Name:DAVIDSON, JESSICA J (RD, CD)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:J
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:WI
Mailing Address - Zip Code:53925-1618
Mailing Address - Country:US
Mailing Address - Phone:920-623-1294
Mailing Address - Fax:920-623-1250
Practice Address - Street 1:1515 PARK AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:WI
Practice Address - Zip Code:53925-1618
Practice Address - Country:US
Practice Address - Phone:920-623-1294
Practice Address - Fax:920-623-1250
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-27
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2618 - 29133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered