Provider Demographics
NPI:1447763529
Name:JACKSON, LAUREN NICOLE (MS, RD)
Entity Type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:NICOLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 SHERWOOD HTS
Mailing Address - Street 2:
Mailing Address - City:WAPPINGERS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12590-3408
Mailing Address - Country:US
Mailing Address - Phone:845-518-1646
Mailing Address - Fax:
Practice Address - Street 1:71 SHERWOOD HTS
Practice Address - Street 2:
Practice Address - City:WAPPINGERS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12590-3408
Practice Address - Country:US
Practice Address - Phone:845-518-1646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-10
Last Update Date:2017-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered