Provider Demographics
NPI:1326414251
Name:ERDELYI, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:ERDELYI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MAE
Other - Last Name:GRILLIOT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD, LD
Mailing Address - Street 1:6421 S RANGELINE RD
Mailing Address - Street 2:
Mailing Address - City:WEST MILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45383-9605
Mailing Address - Country:US
Mailing Address - Phone:937-581-3198
Mailing Address - Fax:
Practice Address - Street 1:100 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-2687
Practice Address - Country:US
Practice Address - Phone:937-523-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-14
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7655133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered