Healthcare Provider Details

I. General information

NPI: 1134535255
Provider Name (Legal Business Name): JESSICA COMBS CAUDILL MS, RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2014
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1548 FLEMISHBOND PATH
LEXINGTON KY
40509-8706
US

IV. Provider business mailing address

1548 FLEMISHBOND PATH
LEXINGTON KY
40509-8706
US

V. Phone/Fax

Practice location:
  • Phone: 859-595-3638
  • Fax:
Mailing address:
  • Phone: 859-595-3638
  • Fax: 859-595-3638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND7422
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number121391
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: