Provider Demographics
NPI:1760510200
Name:JACKO, DANA ANN (RD)
Entity Type:Individual
Prefix:MRS
First Name:DANA
Middle Name:ANN
Last Name:JACKO
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 1:9 BROOKVALE RD
Mailing Address - Street 2:
Mailing Address - City:KINNELON
Mailing Address - State:NJ
Mailing Address - Zip Code:07405-2275
Mailing Address - Country:US
Mailing Address - Phone:973-838-8128
Mailing Address - Fax:
Practice Address - Street 1:9 BROOKVALE RD
Practice Address - Street 2:
Practice Address - City:KINNELON
Practice Address - State:NJ
Practice Address - Zip Code:07405-2275
Practice Address - Country:US
Practice Address - Phone:973-838-8128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ803411133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered