Healthcare Provider Details

I. General information

NPI: 1154421238
Provider Name (Legal Business Name): JESSICA THEOBALD SEYMOUR NUTRITIONIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 N QUEEN ST
KINSTON NC
28501-4932
US

IV. Provider business mailing address

324 N QUEEN ST
KINSTON NC
28501-4932
US

V. Phone/Fax

Practice location:
  • Phone: 252-522-9485
  • Fax:
Mailing address:
  • Phone: 252-522-9485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberL001943
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: