Provider Demographics
NPI:1538282603
Name:JACKSON, LUCY O (MSC, RD,CNS,IBCLC)
Entity Type:Individual
Prefix:MS
First Name:LUCY
Middle Name:O
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSC, RD,CNS,IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 FAIRBURN RD SW STE 350
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-2012
Mailing Address - Country:US
Mailing Address - Phone:404-505-6754
Mailing Address - Fax:404-505-6758
Practice Address - Street 1:515 FAIRBURN RD SW STE 350
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-2012
Practice Address - Country:US
Practice Address - Phone:404-505-6754
Practice Address - Fax:404-505-6758
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD001368133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered