Provider Demographics
NPI:1609194190
Name:TALLMAN, JACK D SR (RD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:D
Last Name:TALLMAN
Suffix:SR
Gender:M
Credentials:RD
Other - Prefix:
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Mailing Address - Street 1:1200 N WEST AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-2179
Mailing Address - Country:US
Mailing Address - Phone:517-789-1234
Mailing Address - Fax:517-784-7040
Practice Address - Street 1:1200 N WEST AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-2179
Practice Address - Country:US
Practice Address - Phone:517-789-1234
Practice Address - Fax:517-784-7040
Is Sole Proprietor?:No
Enumeration Date:2010-05-10
Last Update Date:2010-05-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI807299133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N51670Medicare UPIN