Healthcare Provider Details

I. General information

NPI: 1154860377
Provider Name (Legal Business Name): JESSICA ROBERTSON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2017
Last Update Date: 02/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9402 UPTOWN DR SUITE 1600
INDIANAPOLIS IN
46256-1000
US

IV. Provider business mailing address

11869 BOOTHBAY LN
FISHERS IN
46037-7880
US

V. Phone/Fax

Practice location:
  • Phone: 317-578-0998
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37001344A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: