Provider Demographics
NPI:1609301019
Name:CARPENTER, JESSICA (MA, MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:MA, MS, RD, LD
Other - Prefix:
Other - First Name:JESSIE
Other - Middle Name:
Other - Last Name:CARPENTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, MS, RD, LD
Mailing Address - Street 1:302 STARLIFTER WAY
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31098-1315
Mailing Address - Country:US
Mailing Address - Phone:918-633-8295
Mailing Address - Fax:
Practice Address - Street 1:302 STARLIFTER WAY
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31098-1315
Practice Address - Country:US
Practice Address - Phone:918-633-8295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-23
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1401133V00000X
MSD2350133V00000X
LA3607133V00000X
GALD006614133V00000X
NE1566133V00000X
IA084447133V00000X
WY450133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered