Provider Demographics
NPI:1831214766
Name:HOUDYSHELL, JESSICA (RD, LD, CDE)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:HOUDYSHELL
Suffix:
Gender:F
Credentials:RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4202 S SERGEANT AVE
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-4500
Mailing Address - Country:US
Mailing Address - Phone:417-540-6729
Mailing Address - Fax:
Practice Address - Street 1:29 NW 1ST LN
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:MO
Practice Address - Zip Code:64759-8105
Practice Address - Country:US
Practice Address - Phone:417-681-5263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004008859133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOQ25616Medicare ID - Type Unspecified