Provider Demographics
NPI:1396418125
Name:SHOE, JACQUELINE (RD, LDN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:SHOE
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3029 BECKERDITE RD
Mailing Address - Street 2:
Mailing Address - City:SOPHIA
Mailing Address - State:NC
Mailing Address - Zip Code:27350-8515
Mailing Address - Country:US
Mailing Address - Phone:336-953-9984
Mailing Address - Fax:
Practice Address - Street 1:1100 E WENDOVER AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-6713
Practice Address - Country:US
Practice Address - Phone:336-641-4084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-28
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC86092465133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered