Provider Demographics
NPI:1205534021
Name:ANDERSON, JESSE (RDN, LD)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 GOODWIN CREST DR
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:AL
Mailing Address - Zip Code:35209-3701
Mailing Address - Country:US
Mailing Address - Phone:205-290-4567
Mailing Address - Fax:205-943-4987
Practice Address - Street 1:234 GOODWIN CREST DR
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:AL
Practice Address - Zip Code:35209-3701
Practice Address - Country:US
Practice Address - Phone:205-290-4567
Practice Address - Fax:205-943-4987
Is Sole Proprietor?:No
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86254087133V00000X
AL3352133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86254087OtherCOMMISSION ON DIETETIC REGISTRATION
AL3352OtherALABAMA BOARD OF EXAMINERS FOR DIETETICS AND NUTRITION