Provider Demographics
NPI:1235777335
Name:JACKSON, SERENA FRANCES (RDN)
Entity Type:Individual
Prefix:
First Name:SERENA
Middle Name:FRANCES
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 N R ST
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-5226
Mailing Address - Country:US
Mailing Address - Phone:406-217-8076
Mailing Address - Fax:
Practice Address - Street 1:301 N R ST
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-5226
Practice Address - Country:US
Practice Address - Phone:406-217-8076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-19
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86045354133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered