Provider Demographics
NPI:1780919076
Name:JOHNSON, JESSICA R (RD, LD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:R
Other - Last Name:CONRAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:309 NW ABILENE RD
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-2112
Mailing Address - Country:US
Mailing Address - Phone:515-868-8344
Mailing Address - Fax:641-236-2044
Practice Address - Street 1:GRINNELL REGIONAL MEDICAL CENTER
Practice Address - Street 2:210 4TH AVE
Practice Address - City:GRINNELL
Practice Address - State:IA
Practice Address - Zip Code:50112-1898
Practice Address - Country:US
Practice Address - Phone:641-236-2435
Practice Address - Fax:641-236-2044
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001779133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered