Provider Demographics
NPI:1386188332
Name:JACKSON, KIMBERLY (RDN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2318 LONGCOURT WAY SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-0902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2318 LONGCOURT WAY SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-0902
Practice Address - Country:US
Practice Address - Phone:404-889-7662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-10
Last Update Date:2016-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD004676133V00000X
AL2230133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered