Provider Demographics
NPI:1356978340
Name:JACKSON, TWYLA DOUGLAS I (RDN, CSO, LD)
Entity type:Individual
Prefix:
First Name:TWYLA
Middle Name:DOUGLAS
Last Name:JACKSON
Suffix:I
Gender:F
Credentials:RDN, CSO, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 SUMMIT VILLAGE LN
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-5962
Mailing Address - Country:US
Mailing Address - Phone:404-432-2916
Mailing Address - Fax:
Practice Address - Street 1:CLINICAL NUTRITION
Practice Address - Street 2:1000 JOHNSON FERRY RD NE
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-432-2916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Identifiers
StateIdentifier IDID TypeIssuer
GALD001282OtherSTATE OF GEORGIA LICENSE