MEDICARE: JESSICA CONNELLY RD, 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
1	133V00000X	Registered Dietitian	DT86199	TX

General Provider Information

NPI Number	:	1528929981
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA CONNELLY RD, LD

Provider Business Mailing Address
First Line	:	2117 HAYLEE DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76131-1208
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2117 HAYLEE DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76131-1208
Country	:	US
Telephone Number	:	860-798-3578
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/24/2025
Last Update Date	:	11/24/2025

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