Provider Demographics
NPI:1689294829
Name:JACKSON, JENNIFER K (MPH, RDN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:K
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MPH, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13017 BEAR DANCER TRL NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-3726
Mailing Address - Country:US
Mailing Address - Phone:505-301-0384
Mailing Address - Fax:
Practice Address - Street 1:13017 BEAR DANCER TRL NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-3726
Practice Address - Country:US
Practice Address - Phone:505-301-0384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-17
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLD-1334133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered