Healthcare Provider Details

I. General information

NPI: 1255191094
Provider Name (Legal Business Name): JESSICA SMALLWOOD RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA HEACOCK

II. Dates (important events)

Enumeration Date: 03/20/2024
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HILLSIDE DR
HAMPDEN ME
04444-1721
US

IV. Provider business mailing address

1 HILLSIDE DR
HAMPDEN ME
04444-1721
US

V. Phone/Fax

Practice location:
  • Phone: 207-745-7973
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI1028
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN010329
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: