Basic Information
| Provider Information | |||||||||
| NPI: | 1619451853 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MASSERANO | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 E PARK BLVD STE 206 | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750745472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724229180 | ||||||||
| FaxNumber: | 8478595885 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 E PARK BLVD STE 206 | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750745472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724229180 | ||||||||
| FaxNumber: | 8888212292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2018 | ||||||||
| LastUpdateDate: | 12/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DT85466 | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 417305601 | 05 | TX | MEDICAID |