Healthcare Provider Details

I. General information

NPI: 1760092084
Provider Name (Legal Business Name): JESSICA C WALDEN MS, RD, LD, BBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2020
Last Update Date: 08/02/2020
Certification Date: 08/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1022 NASHMONT DR
ONA WV
25545-9541
US

IV. Provider business mailing address

1022 NASHMONT DR
ONA WV
25545-9541
US

V. Phone/Fax

Practice location:
  • Phone: 304-634-0325
  • Fax:
Mailing address:
  • Phone: 304-634-0325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86029668
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: