Provider Demographics
NPI:1538799275
Name:BRELAND, JESSICA (RD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BRELAND
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 CEDAR GROVE RD
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-5201
Mailing Address - Country:US
Mailing Address - Phone:601-543-3392
Mailing Address - Fax:
Practice Address - Street 1:6414 HIGHWAY 98 WEST
Practice Address - Street 2:SUITE 120
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402
Practice Address - Country:US
Practice Address - Phone:601-296-2833
Practice Address - Fax:601-261-5175
Is Sole Proprietor?:No
Enumeration Date:2020-01-22
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
D1837133VN1201X
MSD1837133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06477724Medicaid