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NPI Code Detail

MEDICARE: JESSICA DIVIS RD

MEDICARE: JESSICA DIVIS RD
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 Dietitian86094146AZ

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
186094146OTHERAZCOMMISON ON DIETETIC REGISTRATION

General Provider Information

NPI Number : 1386222396
Entity Type Code : Individual
Provider Name (Legal Business Name) : JESSICA DIVIS RD
Provider Business Mailing Address
First Line : 2108 E THOMAS RD STE 130
Second Line :
City : PHOENIX
State : AZ
Zip : 85016-0008
Country : US
Telephone Number : 602-933-3124
Fax Number :
Provider Business Practice Location Address
First Line : 1920 E CAMBRIDGE AVE STE 201
Second Line :
City : PHOENIX
State : AZ
Zip : 85006-1462
Country : US
Telephone Number : 602-933-0935
Fax Number : 602-933-2471
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/31/2021
Last Update Date : 03/03/2026

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Directions to “ JESSICA DIVIS RD” Practice Location

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