Healthcare Provider Details

I. General information

NPI: 1457761678
Provider Name (Legal Business Name): JESSICA BLUTO RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2014
Last Update Date: 06/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1909 214TH ST SE STE 211
BOTHELL WA
98021
US

IV. Provider business mailing address

1909 214TH ST SE STE 211
BOTHELL WA
98021-4418
US

V. Phone/Fax

Practice location:
  • Phone: 425-791-3087
  • Fax: 425-791-3088
Mailing address:
  • Phone: 425-791-3087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1139
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: