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NPI Code Detail

MEDICARE: MS. JESSICA ELAINE LAKE MS, RDN, LD

MEDICARE: MS. JESSICA ELAINE LAKE MS, RDN, LD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1133V00000XRegistered DietitianLD.09340OH
2133V00000XRegistered DietitianDN007374PA

General Provider Information

NPI Number : 1154910214
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. JESSICA ELAINE LAKE MS, RDN, LD
Provider Business Mailing Address
First Line : 3910 CAUGHEY RD STE 200
Second Line :
City : ERIE
State : PA
Zip : 16506-4098
Country : US
Telephone Number : 814-580-8808
Fax Number :
Provider Business Practice Location Address
First Line : 3910 CAUGHEY RD STE 200
Second Line :
City : ERIE
State : PA
Zip : 16506-4098
Country : US
Telephone Number : 814-580-8808
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/13/2021
Last Update Date : 09/25/2024

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