Provider Demographics
NPI:1790725034
Name:JACKSON, HELEN D (LD/N)
Entity Type:Individual
Prefix:DR
First Name:HELEN
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 W 6TH ST
Mailing Address - Street 2:MC #24
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32206-4324
Mailing Address - Country:US
Mailing Address - Phone:904-665-2410
Mailing Address - Fax:904-630-3316
Practice Address - Street 1:900 UNIVERSITY BLVD N
Practice Address - Street 2:SUITE 606
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-9203
Practice Address - Country:US
Practice Address - Phone:904-665-2525
Practice Address - Fax:904-745-3099
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND1328133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE8302ZMedicare ID - Type Unspecified