Provider Demographics
NPI:1235751504
Name:HECKROTH, JESSICA LEIGH (MS, RD)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LEIGH
Last Name:HECKROTH
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 E MAIN ST UNIT 558
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-4711
Mailing Address - Country:US
Mailing Address - Phone:904-238-4853
Mailing Address - Fax:
Practice Address - Street 1:633 E MAIN ST UNIT 558
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-4711
Practice Address - Country:US
Practice Address - Phone:904-238-4853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-10
Last Update Date:2020-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY247837133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered