Provider Demographics
NPI:1760422497
Name:JACKSON, SARAH L (RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:SARAH
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5120 JACKSON RD
Mailing Address - Street 2:
Mailing Address - City:MORVEN
Mailing Address - State:GA
Mailing Address - Zip Code:31638-3931
Mailing Address - Country:US
Mailing Address - Phone:229-259-4998
Mailing Address - Fax:
Practice Address - Street 1:2501 N PATTERSON ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1735
Practice Address - Country:US
Practice Address - Phone:229-259-4998
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA135133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00705383AMedicaid
GA00705383AMedicaid
GA71BBBHBMedicare ID - Type UnspecifiedREGISTERED DIETITIAN