Provider Demographics
NPI:1972738268
Name:STERN, JESSICA (MS, RD)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:STERN
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 W WOODLAND RDG
Mailing Address - Street 2:
Mailing Address - City:VALMEYER
Mailing Address - State:IL
Mailing Address - Zip Code:62295-3013
Mailing Address - Country:US
Mailing Address - Phone:618-935-6621
Mailing Address - Fax:
Practice Address - Street 1:1 JEFFERSON BARRACKS DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63125-4181
Practice Address - Country:US
Practice Address - Phone:314-652-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-15
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005002428133V00000X
IL164.004922133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered