Provider Demographics
NPI:1922672716
Name:ANDERSON, JESSALYN (RDN, LD, CDCES)
Entity type:Individual
Prefix:
First Name:JESSALYN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RDN, LD, CDCES
Other - Prefix:
Other - First Name:JESSALYN
Other - Middle Name:
Other - Last Name:RIFE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN, LD
Mailing Address - Street 1:2261 PHILADELPHIA DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-1814
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2261 PHILADELPHIA DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-1814
Practice Address - Country:US
Practice Address - Phone:937-734-6846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
OHLD.09297133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered