Provider Demographics
NPI:1992429526
Name:DEFALCO, JESSICA B (RD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:B
Last Name:DEFALCO
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 1:271 MOLINO AVE APT 8
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-6221
Mailing Address - Country:US
Mailing Address - Phone:707-386-6949
Mailing Address - Fax:
Practice Address - Street 1:271 MOLINO AVE APT 8
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90803-6221
Practice Address - Country:US
Practice Address - Phone:707-386-6949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86290310133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered