Active NPI
Alyssa Rose Jacullo
- Registered Dietitian
- Bala Cynwyd, PA
National Provider Identifier
1952124968
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Registered Dietitian
- License
- DN007895
- Practice address
- 1 Presidential Blvd
Bala Cynwyd, PA 19004-1017 - Phone
- (215) 264-2574
- NPI assigned
- Nov 7, 2024
- Last updated
- Nov 7, 2024
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Registered Dietitian | 133V00000X | DN007895 | PA | Primary |
Addresses
Primary practice location
1 Presidential Blvd
Bala Cynwyd, PA 19004-1017
Mailing address
12430 Wyndom Rd
Philadelphia, PA 19154-1322
Phone (631) 943-1616
Other practice location 1
12430 Wyndom Rd
Philadelphia, PA 19154-1322
Phone (631) 943-1616
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| DN007895 | PA | MD | Registered Dietitian |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Nourish, Inc. | Dietitian, Registered | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1730937600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1730937600000",
"number": "1952124968",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "12430 WYNDOM RD",
"city": "PHILADELPHIA",
"state": "PA",
"postal_code": "191541322",
"telephone_number": "631-943-1616"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1 PRESIDENTIAL BLVD",
"city": "BALA CYNWYD",
"state": "PA",
"postal_code": "190041017",
"telephone_number": "215-264-2574"
}
],
"practiceLocations": [
{
"address_1": "12430 Wyndom Rd",
"address_purpose": "LOCATION",
"city": "Philadelphia",
"state": "PA",
"postal_code": "191541322",
"country_code": "US",
"telephone_number": "631-943-1616",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "JACULLO",
"first_name": "ALYSSA",
"middle_name": "ROSE",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2024-11-07",
"last_updated": "2024-11-07",
"certification_date": "2024-11-07",
"status": "A"
},
"taxonomies": [
{
"code": "133V00000X",
"taxonomy_group": "",
"desc": "Dietitian, Registered",
"state": "PA",
"license": "DN007895",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Bala Cynwyd, PA
- Insight Health Corp (Jefferson Imaging-Bala)
- Institute for Cognitive Prosthetics Inc
- Integrative Psychological & Consulting Services
- Mekayla Dawn Jackson
- Madeia H. Jacobs
- Jason Jaegly, PSY.D.
- Antoine Jahshan, M.D.
- Audre L. Jarmas, PH.D.
- Jodi J Jasionowicz, D.M.D.
- Jefferson Ambulatory Surgery Services, LLC (Jeffeson Endoscopy Center at Bala)
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 7, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.