Provider Demographics
NPI:1962945006
Name:MENDEZ, JESSICA (MS, RDN, CDN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MENDEZ
Suffix:
Gender:F
Credentials:MS, RDN, CDN
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:GWYN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RDN, CDN
Mailing Address - Street 1:2545 SHERIDAN DR
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-9478
Mailing Address - Country:US
Mailing Address - Phone:716-833-4884
Mailing Address - Fax:
Practice Address - Street 1:2545 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14150-9478
Practice Address - Country:US
Practice Address - Phone:716-833-4884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008791133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered