Provider Demographics
NPI:1295138584
Name:AVERILL, JESSICA (RD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:AVERILL
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 1:2687 HILLANDALE DR NW
Mailing Address - Street 2:
Mailing Address - City:WALKER
Mailing Address - State:MI
Mailing Address - Zip Code:49534-1349
Mailing Address - Country:US
Mailing Address - Phone:616-560-5582
Mailing Address - Fax:
Practice Address - Street 1:2215 44TH ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-6439
Practice Address - Country:US
Practice Address - Phone:616-252-8339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-01
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI944934133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered