Provider Demographics
NPI:1477236297
Name:BASTIAN, JESSICA (RD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BASTIAN
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 1:4748 NE 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33334-5610
Mailing Address - Country:US
Mailing Address - Phone:954-651-4748
Mailing Address - Fax:
Practice Address - Street 1:400 NE 3RD AVE APT 1520
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-4099
Practice Address - Country:US
Practice Address - Phone:954-651-4748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND12214133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered