Provider Demographics
NPI:1235323254
Name:BRANTLEY, JESSICA TYNE (RD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:TYNE
Last Name:BRANTLEY
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 1:83389 WEXFORD AVE
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-9616
Mailing Address - Country:US
Mailing Address - Phone:760-272-0948
Mailing Address - Fax:760-342-0444
Practice Address - Street 1:83389 WEXFORD AVE
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-9616
Practice Address - Country:US
Practice Address - Phone:760-272-0948
Practice Address - Fax:760-342-0444
Is Sole Proprietor?:No
Enumeration Date:2007-09-03
Last Update Date:2007-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA934548133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered