Healthcare Provider Details

I. General information

NPI: 1881428795
Provider Name (Legal Business Name): JESSICA ICE RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2024
Last Update Date: 09/02/2024
Certification Date: 09/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 LORI LN
WILMINGTON DE
19809-2329
US

IV. Provider business mailing address

8 LORI LN
WILMINGTON DE
19809-2329
US

V. Phone/Fax

Practice location:
  • Phone: 724-575-2517
  • Fax:
Mailing address:
  • Phone: 724-575-2517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN-0011132
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: