Provider Demographics
NPI:1336626522
Name:IVY, JESSICA (MS, RD, LDN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:IVY
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3404 DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37209-3905
Mailing Address - Country:US
Mailing Address - Phone:214-789-7233
Mailing Address - Fax:833-453-1596
Practice Address - Street 1:5653 FRIST BLVD STE 530
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-2067
Practice Address - Country:US
Practice Address - Phone:214-789-7233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-20
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3139133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered