MEDICARE: CUSTOM NUTRITION COACHING CO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1689517112
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CUSTOM NUTRITION COACHING CO

Provider Business Mailing Address
First Line	:	56 E REDFORD CT
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63304-5048
Country	:	US
Telephone Number	:	618-541-1981
Fax Number	:

Provider Business Practice Location Address
First Line	:	56 E REDFORD CT
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63304-5048
Country	:	US
Telephone Number	:	618-541-1981
Fax Number	:

Authorized Official
Title or Position	:	OWNER, RDN
Name	:	JESSICA NICOLE HUMPHRIES
Credential	:	MS, RDN, LDN, CDCES
Telephone Number	:	618-541-1981

Provider Enumeration Date	:	04/10/2026
Last Update Date	:	04/10/2026

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