Provider Demographics
NPI:1710658273
Name:JACOBS, ASHLEY (RDN, LDN)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10600 CHEVROLET WAY STE 229
Mailing Address - Street 2:
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928-4424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12400 US 2
Practice Address - Street 2:
Practice Address - City:WEST GLACIER
Practice Address - State:MT
Practice Address - Zip Code:59936
Practice Address - Country:US
Practice Address - Phone:520-286-5468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86096619133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered