Basic Information
| Provider Information | |||||||||
| NPI: | 1174001044 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICKLI | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | MA, RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4625 CHAPMAN RD | ||||||||
| Address2: | |||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492859474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8108149018 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4328 PAGE AVE | ||||||||
| Address2: | |||||||||
| City: | MICHIGAN CENTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492541077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347697100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2018 | ||||||||
| LastUpdateDate: | 08/02/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 1089288 | MI | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.