Provider Demographics
NPI:1083485841
Name:HODGES, JACQUELINE (RDN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:HODGES
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 THUNDERBIRD DR N
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-4381
Mailing Address - Country:US
Mailing Address - Phone:662-231-2294
Mailing Address - Fax:
Practice Address - Street 1:1221 THUNDERBIRD DR N
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632-4381
Practice Address - Country:US
Practice Address - Phone:662-231-2294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD-1432133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered