Provider Demographics
NPI:1134139439
Name:ANKLAM, JESSICA C
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:C
Last Name:ANKLAM
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 1:1375 N MAIN ST
Mailing Address - Street 2:ATTN NUTRITIONAL SERVICES
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-1350
Mailing Address - Country:US
Mailing Address - Phone:810-667-5712
Mailing Address - Fax:810-667-5856
Practice Address - Street 1:1375 N MAIN ST
Practice Address - Street 2:ATTN NUTRITIONAL SERVICES
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-1350
Practice Address - Country:US
Practice Address - Phone:810-667-5712
Practice Address - Fax:810-667-5856
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL949603133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered