Provider Demographics
NPI:1033429832
Name:JACKSON, SHANNON BYRD (RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:BYRD
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 TARBORO ST SW
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-3428
Mailing Address - Country:US
Mailing Address - Phone:252-399-8768
Mailing Address - Fax:252-399-7494
Practice Address - Street 1:1705 TARBORO ST SW
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-3428
Practice Address - Country:US
Practice Address - Phone:252-399-8768
Practice Address - Fax:252-399-7494
Is Sole Proprietor?:No
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL002445133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered