Provider Demographics
NPI:1366676439
Name:BLACK, JESSICA DONZE (RD)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:DONZE
Last Name:BLACK
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 1:230 N GRANADA ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22203-1322
Mailing Address - Country:US
Mailing Address - Phone:703-855-2787
Mailing Address - Fax:
Practice Address - Street 1:230 N GRANADA ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22203-1322
Practice Address - Country:US
Practice Address - Phone:703-855-2787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-05
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDI100000167133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered