Provider Demographics
NPI:1790102358
Name:SACKETT, SHELBY JAY (RD, LD)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:JAY
Last Name:SACKETT
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 WESTGATE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1000
Mailing Address - Country:US
Mailing Address - Phone:651-605-2324
Mailing Address - Fax:
Practice Address - Street 1:1045 WESTGATE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1000
Practice Address - Country:US
Practice Address - Phone:651-605-2324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-20
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1120133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered