Provider Demographics
NPI:1184728610
Name:BUSCH, JACKIE (RD)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:BUSCH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-2432
Mailing Address - Country:US
Mailing Address - Phone:770-479-5535
Mailing Address - Fax:770-479-8821
Practice Address - Street 1:320 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2432
Practice Address - Country:US
Practice Address - Phone:770-479-5535
Practice Address - Fax:770-479-8821
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
71BBBFKMedicare ID - Type Unspecified
P69140Medicare UPIN