Provider Demographics
NPI:1770658288
Name:BROZEK, SALLY JACKSON (RD,CDE)
Entity Type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:JACKSON
Last Name:BROZEK
Suffix:
Gender:F
Credentials:RD,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 SUPERIOR AVE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1402
Mailing Address - Country:US
Mailing Address - Phone:404-605-3828
Mailing Address - Fax:404-350-0380
Practice Address - Street 1:1968 PEACHTREE RD NW
Practice Address - Street 2:BUILDING 77
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1281
Practice Address - Country:US
Practice Address - Phone:404-605-3828
Practice Address - Fax:404-350-0380
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD000987133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered