Provider Demographics
NPI:1578279857
Name:MACK, JACLYN M (MS, RDN, LDN)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:M
Last Name:MACK
Suffix:
Gender:F
Credentials:MS, RDN, LDN
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:M
Other - Last Name:MACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:JACLYN MISTRETTA
Mailing Address - Street 1:2488 KNIGHT RD
Mailing Address - Street 2:
Mailing Address - City:PENNSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18073-1974
Mailing Address - Country:US
Mailing Address - Phone:484-995-3989
Mailing Address - Fax:
Practice Address - Street 1:318 MAIN ST APT 4
Practice Address - Street 2:
Practice Address - City:PENNSBURG
Practice Address - State:PA
Practice Address - Zip Code:18073-1326
Practice Address - Country:US
Practice Address - Phone:484-995-3989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered