Provider Demographics
NPI:1972136398
Name:GLOSSON, JESSICA LYN (RDN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYN
Last Name:GLOSSON
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2771 MONUMENT RD STE 33
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-3524
Mailing Address - Country:US
Mailing Address - Phone:904-450-6090
Mailing Address - Fax:
Practice Address - Street 1:2771 MONUMENT RD STE 33
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-3524
Practice Address - Country:US
Practice Address - Phone:904-450-6090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND8145133VN1201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
86068054OtherCDR REGISTRATION ID NUMBER
FLND8145OtherFLORIDA RDN LICENSE NO.