Provider Demographics
NPI:1790160760
Name:WARREN, JACQUELINE (RD, LD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:WARREN
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 1:6111 PEACHTREE DUNWOODY RD
Mailing Address - Street 2:BUILDING E, SUITE 202
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-6049
Mailing Address - Country:US
Mailing Address - Phone:770-698-0909
Mailing Address - Fax:
Practice Address - Street 1:6111 PEACHTREE DUNWOODY RD
Practice Address - Street 2:BUILDING E, SUITE 202
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-6049
Practice Address - Country:US
Practice Address - Phone:770-698-0909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-20
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003058133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered