Provider Demographics
NPI:1558540781
Name:PITTS, JACY WADE (MS,RD,LD)
Entity Type:Individual
Prefix:
First Name:JACY
Middle Name:WADE
Last Name:PITTS
Suffix:
Gender:F
Credentials:MS,RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 JOHNSON FERRY RD NE
Mailing Address - Street 2:SUITE 900
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1626
Mailing Address - Country:US
Mailing Address - Phone:678-420-4211
Mailing Address - Fax:
Practice Address - Street 1:980 JOHNSON FERRY RD NE
Practice Address - Street 2:SUITE 900
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1626
Practice Address - Country:US
Practice Address - Phone:678-420-4211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-24
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002730133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered