Provider Demographics
NPI:1174987143
Name:ORTWEIN, JESSICA (RD, CSOWM)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:ORTWEIN
Suffix:
Gender:F
Credentials:RD, CSOWM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 N 12TH ST
Mailing Address - Street 2:SUITE 612
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2848
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 N 12TH ST
Practice Address - Street 2:SUITE 612
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2848
Practice Address - Country:US
Practice Address - Phone:602-521-3050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-06
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1074991133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered