Provider Demographics
NPI:1396209425
Name:GARDNER, JESSICA (RD, LD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8570 COUNTY ROAD 589
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:TX
Mailing Address - Zip Code:75173-7028
Mailing Address - Country:US
Mailing Address - Phone:936-355-2484
Mailing Address - Fax:
Practice Address - Street 1:8570 CO RD 589
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:TX
Practice Address - Zip Code:75173
Practice Address - Country:US
Practice Address - Phone:936-355-2484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT85686133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered