Provider Demographics
NPI:1215161690
Name:GALLEGO, JESSICA (MS RD LD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GALLEGO
Suffix:
Gender:F
Credentials:MS RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3710 SW 51ST ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-8206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3710 SW 51ST ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-8206
Practice Address - Country:US
Practice Address - Phone:305-527-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-13
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND4652133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered