Provider Demographics
NPI:1477677250
Name:THACKRAY, JESSICA HELEN (RD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:HELEN
Last Name:THACKRAY
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 1:265 WATAUGA DR
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-3853
Mailing Address - Country:US
Mailing Address - Phone:828-773-1069
Mailing Address - Fax:
Practice Address - Street 1:2359 HY 105
Practice Address - Street 2:CDSA OF THE BLUE RIDGE
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607
Practice Address - Country:US
Practice Address - Phone:828-256-5391
Practice Address - Fax:828-265-5394
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL002856133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered