Provider Demographics
NPI:1346766870
Name:JACKSON, JEAN ANN (RD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 435
Mailing Address - Street 2:
Mailing Address - City:CARO
Mailing Address - State:MI
Mailing Address - Zip Code:48723
Mailing Address - Country:US
Mailing Address - Phone:989-673-3141
Mailing Address - Fax:989-673-8471
Practice Address - Street 1:401 NORTH HOOPER STREET
Practice Address - Street 2:
Practice Address - City:CARO
Practice Address - State:MI
Practice Address - Zip Code:48723
Practice Address - Country:US
Practice Address - Phone:989-673-3141
Practice Address - Fax:989-673-8471
Is Sole Proprietor?:No
Enumeration Date:2017-08-16
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390286133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered