Provider Demographics
NPI:1679289433
Name:HICKEY, JACKLYN (RD)
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:
Last Name:HICKEY
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 1:16 WALDO AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-4371
Mailing Address - Country:US
Mailing Address - Phone:978-339-3032
Mailing Address - Fax:
Practice Address - Street 1:49 BARRY RD
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-1138
Practice Address - Country:US
Practice Address - Phone:508-736-5453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered