Provider Demographics
NPI:1487200358
Name:JACKIE CARLSON, RD, LDN, CDE DIABETES CONSULTANT, LLC
Entity Type:Organization
Organization Name:JACKIE CARLSON, RD, LDN, CDE DIABETES CONSULTANT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LDN, CDE
Authorized Official - Phone:716-499-1049
Mailing Address - Street 1:4867 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:ASHVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14710-9603
Mailing Address - Country:US
Mailing Address - Phone:716-499-1049
Mailing Address - Fax:
Practice Address - Street 1:4867 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:ASHVILLE
Practice Address - State:NY
Practice Address - Zip Code:14710-9603
Practice Address - Country:US
Practice Address - Phone:716-499-1049
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Single Specialty