Provider Demographics
NPI:1689258709
Name:ALDREDGE, JESSICA (FNTP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:ALDREDGE
Suffix:
Gender:F
Credentials:FNTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4514 FAIRWAY AVE
Mailing Address - Street 2:ORIGIN FUNCTIONAL NUTRITION
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-4354
Mailing Address - Country:US
Mailing Address - Phone:512-963-1131
Mailing Address - Fax:
Practice Address - Street 1:4514 FAIRWAY AVE
Practice Address - Street 2:ORIGIN FUNCTIONAL NUTRITION
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-7521
Practice Address - Country:US
Practice Address - Phone:512-963-1131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-06
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist