Provider Demographics
NPI:1306216437
Name:ROMAN, JESSICA (RD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:ROMAN
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 1:3213 S WALNUT SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-7424
Mailing Address - Country:US
Mailing Address - Phone:260-227-1174
Mailing Address - Fax:
Practice Address - Street 1:1136 W 17TH ST
Practice Address - Street 2:STE. B
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-3002
Practice Address - Country:US
Practice Address - Phone:260-227-1174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN86052599133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered