Provider Demographics
NPI:1376092494
Name:PARHAM, JACLYNN J (RD, LDN, CNSC)
Entity Type:Individual
Prefix:
First Name:JACLYNN
Middle Name:J
Last Name:PARHAM
Suffix:
Gender:F
Credentials:RD, LDN, CNSC
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:J
Other - Last Name:BRENNAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:409 S 2ND ST
Mailing Address - Street 2:SUITE #2F
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1612
Mailing Address - Country:US
Mailing Address - Phone:717-782-5283
Mailing Address - Fax:717-782-5192
Practice Address - Street 1:111 S FRONT ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17101-2010
Practice Address - Country:US
Practice Address - Phone:717-782-5283
Practice Address - Fax:717-782-5192
Is Sole Proprietor?:No
Enumeration Date:2016-09-30
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN005848133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103229258Medicaid
PA547629Medicare PIN