Provider Demographics
NPI:1477760205
Name:JACKSON, MARY ELLEN (RD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
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 1:473 E GREENVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:IN
Mailing Address - Zip Code:47394-9436
Mailing Address - Country:US
Mailing Address - Phone:765-584-0207
Mailing Address - Fax:765-584-0593
Practice Address - Street 1:473 E GREENVILLE AVE
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:IN
Practice Address - Zip Code:47394-9436
Practice Address - Country:US
Practice Address - Phone:765-584-0207
Practice Address - Fax:765-584-0593
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001130A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN179230XMedicare ID - Type Unspecified