Provider Demographics
NPI:1508985151
Name:STANTON, JESSICA NICOLE (RD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:STANTON
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 1:5109 NOR BATH BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18067-9058
Mailing Address - Country:US
Mailing Address - Phone:610-349-3851
Mailing Address - Fax:
Practice Address - Street 1:650 JOEL DR
Practice Address - Street 2:BLANCHFIELD ARMY COMMUNITY HOSIPTAL
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5318
Practice Address - Country:US
Practice Address - Phone:270-798-8077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002684133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered