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NPI Code Detail

MEDICARE: JESSICA LYNN BERENS RD, LDN

MEDICARE: JESSICA LYNN BERENS RD, LDN
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 DietitianL005057NC

General Provider Information

NPI Number : 1528505872
Entity Type Code : Individual
Provider Name (Legal Business Name) : JESSICA LYNN BERENS RD, LDN
Provider Business Mailing Address
First Line : 6633 FAIRVIEW RD
Second Line :
City : CHARLOTTE
State : NC
Zip : 28210-3321
Country : US
Telephone Number : 704-366-1264
Fax Number :
Provider Business Practice Location Address
First Line : 6633 FAIRVIEW RD
Second Line :
City : CHARLOTTE
State : NC
Zip : 28210-3321
Country : US
Telephone Number : 704-366-1264
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/25/2017
Last Update Date : 01/25/2017

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