Healthcare Provider Details

I. General information

NPI: 1063843878
Provider Name (Legal Business Name): JESSICA CAUDELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2013
Last Update Date: 04/13/2020
Certification Date: 04/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 VICTORY CT
WEST CHESTER OH
45069-8655
US

IV. Provider business mailing address

3958 BROWN PARK DR STE D
HILLIARD OH
43026-1160
US

V. Phone/Fax

Practice location:
  • Phone: 513-289-8374
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number7018
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: