Provider Demographics
NPI:1265551188
Name:BOGLE, JESSICA LYN (RD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYN
Last Name:BOGLE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 W NORTHRUP ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-3702
Mailing Address - Country:US
Mailing Address - Phone:517-331-6669
Mailing Address - Fax:
Practice Address - Street 1:2710 S WASHINGTON
Practice Address - Street 2:SUITE 100
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910
Practice Address - Country:US
Practice Address - Phone:517-272-1380
Practice Address - Fax:517-272-1384
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered