Provider Demographics
NPI:1063838555
Name:LEONARD, JESSICA BRIE (RD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:BRIE
Last Name:LEONARD
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 1:300 LONGWOOD AVE
Mailing Address - Street 2:BOSTON CHILDREN'S HOSPITAL, CENTER FOR NUTRITION
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5724
Mailing Address - Country:US
Mailing Address - Phone:617-355-4677
Mailing Address - Fax:
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:BOSTON CHILDREN'S HOSPITAL, CENTER FOR NUTRITION
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-4677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-09
Last Update Date:2014-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3604133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA97802Medicare PIN
MA97803Medicare PIN
MA98961Medicare PIN
MAG0721Medicare PIN
MAG0720Medicare PIN
MA98960Medicare PIN
MA97804Medicare PIN
MA98962Medicare PIN