Provider Demographics
NPI:1942291935
Name:CARLSON, JACQUELINE (RD CDE)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:CARLSON
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 1:145 W 23RD ST STE 202
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16502-2858
Mailing Address - Country:US
Mailing Address - Phone:814-835-2626
Mailing Address - Fax:814-835-2646
Practice Address - Street 1:145 W 23RD ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16502-2858
Practice Address - Country:US
Practice Address - Phone:814-835-2626
Practice Address - Fax:814-835-2646
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000806133VN1006X
PADN006773133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY005261701OtherBLUE CROSS
NY051101000071OtherFIDELIS
NYB42782Medicare UPIN
NYDD0037Medicare ID - Type Unspecified