Healthcare Provider Details

I. General information

NPI: 1659706158
Provider Name (Legal Business Name): JESSICA MOURA MS, RD, CSSD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA MURRAY RD

II. Dates (important events)

Enumeration Date: 09/04/2013
Last Update Date: 04/26/2020
Certification Date: 04/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JARRETT WHITE RD
TRIPLER ARMY MEDICAL CENTER HI
96859-5001
US

IV. Provider business mailing address

758 SAINT MICHAEL ST APT 413
MOBILE AL
36602-1305
US

V. Phone/Fax

Practice location:
  • Phone: 253-691-7037
  • Fax:
Mailing address:
  • Phone: 253-691-7037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number9674
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number60537083
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: