Provider Demographics
NPI:1942765714
Name:ANSELLO, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:ANSELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 SKIPPACK PIKE STE 300
Mailing Address - Street 2:
Mailing Address - City:BLUE BELL
Mailing Address - State:PA
Mailing Address - Zip Code:19422-1749
Mailing Address - Country:US
Mailing Address - Phone:215-628-4454
Mailing Address - Fax:
Practice Address - Street 1:725 SKIPPACK PIKE STE 300
Practice Address - Street 2:
Practice Address - City:BLUE BELL
Practice Address - State:PA
Practice Address - Zip Code:19422-1749
Practice Address - Country:US
Practice Address - Phone:215-628-4454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty