Provider Demographics
NPI:1629211958
Name:JACKSON, SHENEDA L (RD)
Entity Type:Individual
Prefix:
First Name:SHENEDA
Middle Name:L
Last Name:JACKSON
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 1:21 DAUTERIVE CT
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-2478
Mailing Address - Country:US
Mailing Address - Phone:504-473-1106
Mailing Address - Fax:
Practice Address - Street 1:111 N CAUSEWAY BLVD
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-5450
Practice Address - Country:US
Practice Address - Phone:504-838-5100
Practice Address - Fax:504-838-5104
Is Sole Proprietor?:No
Enumeration Date:2009-04-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1730133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3B092Medicare PIN
LA3B0927061Medicare PIN