Provider Demographics
NPI:1639577497
Name:JESSESSKY, COLLEEN R (RD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:R
Last Name:JESSESSKY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:R
Other - Last Name:KOSLOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:17505 N 79TH AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8725
Mailing Address - Country:US
Mailing Address - Phone:623-399-6825
Mailing Address - Fax:623-505-3474
Practice Address - Street 1:14045 N 7TH ST
Practice Address - Street 2:SUITE 4
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-4388
Practice Address - Country:US
Practice Address - Phone:623-399-6825
Practice Address - Fax:623-505-3474
Is Sole Proprietor?:No
Enumeration Date:2014-12-10
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86028282133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered