Provider Demographics
NPI:1215563689
Name:JACKSON, MICHELLE (MS, RD, CDN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS, RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 MELBOURNE AVE
Mailing Address - Street 2:
Mailing Address - City:MAMARONECK
Mailing Address - State:NY
Mailing Address - Zip Code:10543-2726
Mailing Address - Country:US
Mailing Address - Phone:914-777-1809
Mailing Address - Fax:
Practice Address - Street 1:500 BERGEN AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-4048
Practice Address - Country:US
Practice Address - Phone:718-401-5175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-18
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003365-01133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty