=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053975987
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA GRACE ANDERSON MS,RD,CSSD,LD,EPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2019
-----------------------------------------------------
Last Update Date | 03/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2817 ROCK MERRITT AVE WOMACK ARMY MEDICAL CENTER
-----------------------------------------------------
City | FORT BRAGG
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28310-5438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-907-8116
-----------------------------------------------------
Fax | 910-907-6069
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | WOMACK ARMY MEDICAL CENTER 2817 ROCK MERRITT AVE
-----------------------------------------------------
City | FORT BRAGG
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28310-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-907-8116
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133N00000X
-----------------------------------------------------
Taxonomy Name | Nutritionist
-----------------------------------------------------
License Number | 08619
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | LD.08619
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 133N00000X
-----------------------------------------------------
Taxonomy Name | Nutritionist
-----------------------------------------------------
License Number | L007668
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------