Provider Demographics
NPI:1174114672
Name:BLOOD, JESSICA WINNIE (RD)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:WINNIE
Last Name:BLOOD
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 1:30 CHESTNUT ST APT 1
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-3606
Mailing Address - Country:US
Mailing Address - Phone:631-252-3337
Mailing Address - Fax:
Practice Address - Street 1:200 GROTON RD
Practice Address - Street 2:
Practice Address - City:AYER
Practice Address - State:MA
Practice Address - Zip Code:01432-1168
Practice Address - Country:US
Practice Address - Phone:978-784-9314
Practice Address - Fax:978-784-9889
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5116133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered