Healthcare Provider Details

I. General information

NPI: 1730203449
Provider Name (Legal Business Name): JESSICA ANN CAMPBELL RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 JENNINGS STATION RD
SAINT LOUIS MO
63121-3323
US

IV. Provider business mailing address

2705 POMME MEADOWS DR
ARNOLD MO
63010-2868
US

V. Phone/Fax

Practice location:
  • Phone: 314-679-7830
  • Fax:
Mailing address:
  • Phone: 314-650-2624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2005001323
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: