Provider Demographics
NPI:1578516605
Name:CHESTNUT, JACQUELINE ROSE (RD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ROSE
Last Name:CHESTNUT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 OAKRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:GA
Mailing Address - Zip Code:31029-9588
Mailing Address - Country:US
Mailing Address - Phone:478-954-4185
Mailing Address - Fax:
Practice Address - Street 1:350 HOSPITAL DR
Practice Address - Street 2:COLISEUM MEDICAL CENTER
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31208
Practice Address - Country:US
Practice Address - Phone:478-765-4189
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002040133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered