=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942440920
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA DELOS REYES WILLSEY MPH, RDN, LDN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2009
-----------------------------------------------------
Last Update Date | 05/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10000 CHALAN KANOA, PMB 532
-----------------------------------------------------
City | SAIPAN
-----------------------------------------------------
State | MP
-----------------------------------------------------
Zip | 96950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 670-484-4300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PMB 532, BOX 10000
-----------------------------------------------------
City | SAIPAN
-----------------------------------------------------
State | MP
-----------------------------------------------------
Zip | 96950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 670-484-4300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133VN1005X
-----------------------------------------------------
Taxonomy Name | Renal Nutrition Registered Dietitian
-----------------------------------------------------
License Number | LD002840
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 133VN1005X
-----------------------------------------------------
Taxonomy Name | Renal Nutrition Registered Dietitian
-----------------------------------------------------
License Number | 948371
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | LD002840
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | 948371
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------