Provider Demographics
NPI:1114510807
Name:ROBERGE, JESSICA FAVAZZA (RD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:FAVAZZA
Last Name:ROBERGE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:GRACE
Other - Last Name:FAVAZZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:PO BOX 412503
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-2503
Mailing Address - Country:US
Mailing Address - Phone:603-610-8079
Mailing Address - Fax:
Practice Address - Street 1:67 CORPORATE DR STE 300
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-2847
Practice Address - Country:US
Practice Address - Phone:603-610-8079
Practice Address - Fax:603-868-8375
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-15
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1052133VN1201X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management