Provider Demographics
NPI:1932642535
Name:MONGER, JESSICA MARIE (MS/RD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:MONGER
Suffix:
Gender:F
Credentials:MS/RD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MARIE
Other - Last Name:KUTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7 WATER ST
Mailing Address - Street 2:
Mailing Address - City:WELLSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16901-1126
Mailing Address - Country:US
Mailing Address - Phone:570-724-1010
Mailing Address - Fax:570-724-3970
Practice Address - Street 1:7 WATER ST
Practice Address - Street 2:
Practice Address - City:WELLSBORO
Practice Address - State:PA
Practice Address - Zip Code:16901-1126
Practice Address - Country:US
Practice Address - Phone:570-724-1010
Practice Address - Fax:570-724-3970
Is Sole Proprietor?:No
Enumeration Date:2016-11-30
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN004305133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered