Provider Demographics
NPI:1477943652
Name:JACKSON, KAELY (RD/LD)
Entity Type:Individual
Prefix:
First Name:KAELY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CHILDRENS AVE
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-4637
Mailing Address - Country:US
Mailing Address - Phone:405-271-5400
Mailing Address - Fax:
Practice Address - Street 1:1200 CHILDRENS AVE
Practice Address - Street 2:SUITE 1A
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-4637
Practice Address - Country:US
Practice Address - Phone:405-271-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-27
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1961133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered