Provider Demographics
NPI:1134428212
Name:RYAN, JESSICA KIVETT (RD, LD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:KIVETT
Last Name:RYAN
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 S 8TH ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4201
Mailing Address - Country:US
Mailing Address - Phone:770-228-7394
Mailing Address - Fax:770-233-5532
Practice Address - Street 1:610 S 8TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4201
Practice Address - Country:US
Practice Address - Phone:770-228-7394
Practice Address - Fax:770-233-5532
Is Sole Proprietor?:No
Enumeration Date:2011-03-15
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003540133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered