Provider Demographics
NPI:1225212046
Name:GOSCH, JESSICA RAE (RD, CD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RAE
Last Name:GOSCH
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 769
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98338-0769
Mailing Address - Country:US
Mailing Address - Phone:877-508-7229
Mailing Address - Fax:
Practice Address - Street 1:315 MARTIN LUTHER KING JR. WAY, MS: 315-K1-NS
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405
Practice Address - Country:US
Practice Address - Phone:877-508-7229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00001674133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered