Provider Demographics
NPI:1598413551
Name:HACKETT, JACQUELYN (RD)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:HACKETT
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 1:12411 W FIELDING CIR APT 4230
Mailing Address - Street 2:
Mailing Address - City:PLAYA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:90094-2583
Mailing Address - Country:US
Mailing Address - Phone:626-353-7606
Mailing Address - Fax:
Practice Address - Street 1:12411 W FIELDING CIR APT 4230
Practice Address - Street 2:
Practice Address - City:PLAYA VISTA
Practice Address - State:CA
Practice Address - Zip Code:90094-2583
Practice Address - Country:US
Practice Address - Phone:626-353-7606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-17
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86100274133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered