Provider Demographics
NPI:1225334709
Name:JACKSON, KAYLEN MCNAMARA JAMES (RD, LD, CDE)
Entity Type:Individual
Prefix:MS
First Name:KAYLEN
Middle Name:MCNAMARA JAMES
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RD, LD, CDE
Other - Prefix:
Other - First Name:KAYLEN
Other - Middle Name:MCNAMARA
Other - Last Name:JAMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:8170 33RD AVENUE SOUTH
Mailing Address - Street 2:MAIL STOP 21110Q
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440
Mailing Address - Country:US
Mailing Address - Phone:952-883-6212
Mailing Address - Fax:
Practice Address - Street 1:1415 SAINT FRANCIS AVE
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-3374
Practice Address - Country:US
Practice Address - Phone:952-993-3742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-01
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN01021614133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered