Provider Demographics
NPI:1598986093
Name:JASKOWSKI, MELISSA R (RD)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:R
Last Name:JASKOWSKI
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MRS
Other - First Name:MELISSA
Other - Middle Name:R
Other - Last Name:WORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:6474 BOYNE CITY RD
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-9486
Mailing Address - Country:US
Mailing Address - Phone:231-590-4007
Mailing Address - Fax:231-753-1170
Practice Address - Street 1:2609 CHARLEVOIX RD
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8524
Practice Address - Country:US
Practice Address - Phone:231-590-4007
Practice Address - Fax:231-753-1170
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI857689133V00000X
MI00857689133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION61380Medicare UPIN