Provider Demographics
NPI:1336465913
Name:JACKSON, BEVERLY P (ŇD)
Entity Type:Individual
Prefix:DR
First Name:BEVERLY
Middle Name:P
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ŇD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 SILK ST
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06850-2916
Mailing Address - Country:US
Mailing Address - Phone:203-962-2995
Mailing Address - Fax:
Practice Address - Street 1:19 SILK ST
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850-2916
Practice Address - Country:US
Practice Address - Phone:203-962-2995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-08
Last Update Date:2016-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND00001 FEDERAL LIC.133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist