Provider Demographics
NPI:1376835298
Name:JACKSON, MARY BICKEL (CERTIFIED DIETITIAN/)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:BICKEL
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CERTIFIED DIETITIAN/
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 FULTON PLAZA
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940
Mailing Address - Country:US
Mailing Address - Phone:845-346-1300
Mailing Address - Fax:845-346-1298
Practice Address - Street 1:33 FULTON PLAZA
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940
Practice Address - Country:US
Practice Address - Phone:845-346-1300
Practice Address - Fax:845-346-1298
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-11
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004474-1133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist