Provider Demographics
NPI:1609518505
Name:JACKSON, MCKENZIE (RD, LDN)
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:MCKENZIE
Other - Middle Name:
Other - Last Name:CARVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LDN
Mailing Address - Street 1:1923 HAMPTON DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-4236
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1923 HAMPTON DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-4236
Practice Address - Country:US
Practice Address - Phone:615-974-7451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4062133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered