Provider Demographics
NPI:1952448466
Name:JACK-BRISSEAU, SHERMA (NUTRI)
Entity Type:Individual
Prefix:MS
First Name:SHERMA
Middle Name:
Last Name:JACK-BRISSEAU
Suffix:
Gender:F
Credentials:NUTRI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 EAST JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-7446
Mailing Address - Fax:301-816-7170
Practice Address - Street 1:5100 AUTH WAY
Practice Address - Street 2:
Practice Address - City:SUITLAND
Practice Address - State:MD
Practice Address - Zip Code:20746-4207
Practice Address - Country:US
Practice Address - Phone:301-702-5250
Practice Address - Fax:301-702-5262
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDN00207133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist