Provider Demographics
NPI:1750984076
Name:COOPER, JESSICA (RD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:COOPER
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 1:1545 S 1900 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-2653
Mailing Address - Country:US
Mailing Address - Phone:801-599-7965
Mailing Address - Fax:
Practice Address - Street 1:1545 S 1900 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-2653
Practice Address - Country:US
Practice Address - Phone:801-599-7965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3083154-4901133VN1501X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1501XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Sports Dietetics