Provider Demographics
NPI:1316602766
Name:THOMAS, JESSIE XIAOYUN (RD)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:XIAOYUN
Last Name:THOMAS
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:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:3508 S LIVE OAK DR
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-8737
Practice Address - Country:US
Practice Address - Phone:884-399-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-01
Last Update Date:2021-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86211453133V00000X
SC2277133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered