Provider Demographics
NPI:1598070005
Name:BRAXTON, JESSICA SUTTON (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:SUTTON
Last Name:BRAXTON
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 1:305 TIMBERWIND DR
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:GA
Mailing Address - Zip Code:31008-9540
Mailing Address - Country:US
Mailing Address - Phone:478-952-8577
Mailing Address - Fax:478-953-6556
Practice Address - Street 1:305 TIMBERWIND DR
Practice Address - Street 2:
Practice Address - City:BYRON
Practice Address - State:GA
Practice Address - Zip Code:31008-9540
Practice Address - Country:US
Practice Address - Phone:478-952-8577
Practice Address - Fax:478-953-6556
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002820133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered