Provider Demographics
NPI:1093332074
Name:JACKSON, YOLANDA LETRICE (MS, RD, LD)
Entity Type:Individual
Prefix:MS
First Name:YOLANDA
Middle Name:LETRICE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 GREENDALE RD UNIT 14103
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-8350
Mailing Address - Country:US
Mailing Address - Phone:859-533-2136
Mailing Address - Fax:
Practice Address - Street 1:1024 GREENDALE RD UNIT 14103
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40511-8350
Practice Address - Country:US
Practice Address - Phone:859-533-2136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-25
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY122310133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered