=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346639721
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA GLOSS M.S., R.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2015
-----------------------------------------------------
Last Update Date | 01/22/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1477 BEACON ST APT 104
-----------------------------------------------------
City | BROOKLINE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02446-4738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-500-6914
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1477 BEACON ST APT 104
-----------------------------------------------------
City | BROOKLINE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02446-4738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-500-6914
-----------------------------------------------------
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 | 1064444
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | 1064444
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 133VN1004X
-----------------------------------------------------
Taxonomy Name | Pediatric Nutrition Registered Dietitian
-----------------------------------------------------
License Number | 1064444
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 133VN1005X
-----------------------------------------------------
Taxonomy Name | Renal Nutrition Registered Dietitian
-----------------------------------------------------
License Number | 1064444
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 133VN1006X
-----------------------------------------------------
Taxonomy Name | Metabolic Nutrition Registered Dietitian
-----------------------------------------------------
License Number | 1064444
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------