Provider Demographics
NPI:1164970497
Name:ATCHISON, MARY JO (MS,RD,CDE)
Entity Type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:ATCHISON
Suffix:
Gender:F
Credentials:MS,RD,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 S PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-3488
Mailing Address - Country:US
Mailing Address - Phone:517-975-2198
Mailing Address - Fax:517-975-2200
Practice Address - Street 1:2727 S PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-3488
Practice Address - Country:US
Practice Address - Phone:517-975-2198
Practice Address - Fax:517-975-2200
Is Sole Proprietor?:No
Enumeration Date:2016-09-15
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI00542657133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered