Provider Demographics
NPI:1144738048
Name:GRIFFEL, JESSICA BADARACCO (RDN, LD)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:BADARACCO
Last Name:GRIFFEL
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:BADARACCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:990 CESAR CHAVEZ AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83209-0001
Mailing Address - Country:US
Mailing Address - Phone:208-282-2330
Mailing Address - Fax:
Practice Address - Street 1:990 CESAR CHAVEZ AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-0001
Practice Address - Country:US
Practice Address - Phone:208-282-2330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-14
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT66610133V00000X
ID86051010133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered