Provider Demographics
NPI:1548567043
Name:JACKSON, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 SE ARMY POST RD
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50315-5942
Mailing Address - Country:US
Mailing Address - Phone:515-285-6394
Mailing Address - Fax:
Practice Address - Street 1:1107 SE ARMY POST RD
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50315-5942
Practice Address - Country:US
Practice Address - Phone:515-285-6394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-17
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA11511142Medicaid
IA11511142Medicare PIN