Provider Demographics
NPI:1134364029
Name:JACKSON, STEVEN JAC TODD (PHD, RD)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:JAC TODD
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PHD, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 MAIN ST
Mailing Address - Street 2:APT. 1606
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-2061
Mailing Address - Country:US
Mailing Address - Phone:618-203-4426
Mailing Address - Fax:
Practice Address - Street 1:15 KANSAS STREET, BLDG 42
Practice Address - Street 2:USARIEM-MND
Practice Address - City:NATICK
Practice Address - State:MA
Practice Address - Zip Code:01760
Practice Address - Country:US
Practice Address - Phone:508-233-5808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-08
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.004841133V00000X
GALD003265133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered