Provider Demographics
NPI:1235795386
Name:BUSH, JESSICA (RDN, LD, MPH)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BUSH
Suffix:
Gender:F
Credentials:RDN, LD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2708 BRAELINN PKWY N
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:AL
Mailing Address - Zip Code:35080-3748
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2708 BRAELINN PKWY N
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:AL
Practice Address - Zip Code:35080-3748
Practice Address - Country:US
Practice Address - Phone:740-501-1443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2751133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered