Provider Demographics
NPI:1356012348
Name:HUMPHRIES, JESSICA NICOLE (RD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:HUMPHRIES
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:NICOLE
Other - Last Name:ORSCHELN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:PO BOX 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:314-851-1000
Mailing Address - Fax:
Practice Address - Street 1:1721 HERITAGE HILLS DR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-4621
Practice Address - Country:US
Practice Address - Phone:314-851-1000
Practice Address - Fax:314-851-4445
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019040081133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered