Provider Demographics
NPI:1235321837
Name:PHILIP, JESSY (PHD,RD,LDN)
Entity type:Individual
Prefix:
First Name:JESSY
Middle Name:
Last Name:PHILIP
Suffix:
Gender:F
Credentials:PHD,RD,LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 KEEVER ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLNTON
Mailing Address - State:NC
Mailing Address - Zip Code:28092-8362
Mailing Address - Country:US
Mailing Address - Phone:704-345-8729
Mailing Address - Fax:704-732-0811
Practice Address - Street 1:107 KEEVER ST
Practice Address - Street 2:
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092-8362
Practice Address - Country:US
Practice Address - Phone:704-345-8729
Practice Address - Fax:704-732-0811
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL002589133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered