Provider Demographics
NPI:1164869491
Name:VEGA, JACKIE (MS, RDN, LDN)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:VEGA
Suffix:
Gender:F
Credentials:MS, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1691 FORUM PL
Mailing Address - Street 2:SUITE B #321
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401
Mailing Address - Country:US
Mailing Address - Phone:407-353-6929
Mailing Address - Fax:
Practice Address - Street 1:1691 FORUM PL
Practice Address - Street 2:SUITE B #321
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-2336
Practice Address - Country:US
Practice Address - Phone:407-353-6929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-28
Last Update Date:2025-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
FLND8689133V00000X
GALD007550133V00000X
IL164.012066133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered