Provider Demographics
NPI:1467923680
Name:JACKSON, SIR BENJOMYNE JAIMES (RDN)
Entity Type:Individual
Prefix:
First Name:SIR BENJOMYNE
Middle Name:JAIMES
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10461 QUALITY DR
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-9634
Mailing Address - Country:US
Mailing Address - Phone:352-688-3026
Mailing Address - Fax:
Practice Address - Street 1:10461 QUALITY DR
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34609-9634
Practice Address - Country:US
Practice Address - Phone:352-688-3026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND8653133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered