Healthcare Provider Details

I. General information

NPI: 1407602253
Provider Name (Legal Business Name): JESSICA M GREGOIRE RDN, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2024
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14688 EVERTON AVE N
HUGO MN
55038-6071
US

IV. Provider business mailing address

2025 SLOAN PL STE 35
SAINT PAUL MN
55117-2092
US

V. Phone/Fax

Practice location:
  • Phone: 651-328-8405
  • Fax: 651-429-3402
Mailing address:
  • Phone: 651-772-1572
  • Fax: 651-772-1889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number4239
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: