Provider Demographics
NPI:1417334681
Name:JACKSON, JENNA (RD)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
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 1:4322 MATILIJA AVE
Mailing Address - Street 2:APT 2
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-3624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11165 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-1113
Practice Address - Country:US
Practice Address - Phone:866-837-5779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-27
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1071091133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered