Provider Demographics
NPI:1487067575
Name:AMIDON, JESSICA
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:
Last Name:AMIDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 SURREY ST
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-2633
Mailing Address - Country:US
Mailing Address - Phone:617-319-4797
Mailing Address - Fax:
Practice Address - Street 1:71 SURREY ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-2633
Practice Address - Country:US
Practice Address - Phone:617-319-4797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist