Provider Demographics
NPI:1609091040
Name:ACOSTA, JESSICA G (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:G
Last Name:ACOSTA
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2203 BABCOCK RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4412
Mailing Address - Country:US
Mailing Address - Phone:210-643-6792
Mailing Address - Fax:
Practice Address - Street 1:14207 HIGGINS RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-1252
Practice Address - Country:US
Practice Address - Phone:210-826-4492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX968469133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered