Provider Demographics
NPI:1194381913
Name:JACKSON, PRESTON REID (RD)
Entity Type:Individual
Prefix:MR
First Name:PRESTON
Middle Name:REID
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18137 W CATAWBA AVE
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-5641
Mailing Address - Country:US
Mailing Address - Phone:704-549-9550
Mailing Address - Fax:
Practice Address - Street 1:18137 W CATAWBA AVE
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-5641
Practice Address - Country:US
Practice Address - Phone:704-549-9550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-16
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL005756133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered