Provider Demographics
NPI:1164849816
Name:MACKEY, JESSICA CECIL (MPH, RD, CSP, LD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:CECIL
Last Name:MACKEY
Suffix:
Gender:F
Credentials:MPH, RD, CSP, LD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:M
Other - Last Name:CECIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPHRD
Mailing Address - Street 1:5471 DR MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-4265
Mailing Address - Country:US
Mailing Address - Phone:314-367-5820
Mailing Address - Fax:314-367-7010
Practice Address - Street 1:5471 DR MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-4265
Practice Address - Country:US
Practice Address - Phone:314-367-5820
Practice Address - Fax:314-367-7010
Is Sole Proprietor?:No
Enumeration Date:2014-03-19
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011028874133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered