Provider Demographics
NPI:1710632393
Name:KAYLEN JACKSON NUTRITION LLC
Entity Type:Organization
Organization Name:KAYLEN JACKSON NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LEAD DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:KAYLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LD, CDCES
Authorized Official - Phone:612-306-1939
Mailing Address - Street 1:4005 MONTEREY AVE
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55416-5046
Mailing Address - Country:US
Mailing Address - Phone:612-306-1939
Mailing Address - Fax:
Practice Address - Street 1:4005 MONTEREY AVE
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55416-5046
Practice Address - Country:US
Practice Address - Phone:612-306-1939
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-13
Last Update Date:2022-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty