Provider Demographics
NPI:1346311008
Name:JACKSON, SHARON DENISE (MS RD CDE)
Entity Type:Individual
Prefix:MRS
First Name:SHARON
Middle Name:DENISE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS RD CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6 NEWCROFT CIRCLE
Mailing Address - Street 2:
Mailing Address - City:MATTAPAN
Mailing Address - State:MA
Mailing Address - Zip Code:02126
Mailing Address - Country:US
Mailing Address - Phone:617-296-3987
Mailing Address - Fax:617-713-3438
Practice Address - Street 1:1425 BLUE HILLS AVE
Practice Address - Street 2:MATTAPAN COMMUNITY HEALTH CTR
Practice Address - City:MATTAPAN
Practice Address - State:MA
Practice Address - Zip Code:02126
Practice Address - Country:US
Practice Address - Phone:617-898-9052
Practice Address - Fax:617-713-3438
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1031133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist