MEDICARE: ON THE MOVE NUTRITION

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1467929125	OTHER		INDIVIDUAL NPI
2	LD.08277	OTHER	OH	LICENSURE

General Provider Information

NPI Number	:	1902417058
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ON THE MOVE NUTRITION

Provider Business Mailing Address
First Line	:	14837 DETROIT AVE STE 189
Second Line	:
City	:	LAKEWOOD
State	:	OH
Zip	:	44107-3909
Country	:	US
Telephone Number	:	440-865-1266
Fax Number	:

Provider Business Practice Location Address
First Line	:	9712 BALTIC RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44102-1719
Country	:	US
Telephone Number	:	440-865-1266
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JESSICA MARIE JURCAK
Credential	:	MS, MPH, RD, LD
Telephone Number	:	440-865-1266

Provider Enumeration Date	:	08/12/2020
Last Update Date	:	08/12/2020

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Directions to “ON THE MOVE NUTRITION ” Practice Location

Language	Start Address	Practice Location

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