Provider Demographics
NPI:1093305674
Name:THONGPARN, JESSICA LAUREN (RD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LAUREN
Last Name:THONGPARN
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 1:204 NEW HAVEN AVE UNIT 8C
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-2150
Mailing Address - Country:US
Mailing Address - Phone:860-806-5013
Mailing Address - Fax:
Practice Address - Street 1:204 NEW HAVEN AVE UNIT 8C
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418-2150
Practice Address - Country:US
Practice Address - Phone:860-806-5013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT957503133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered