Provider Demographics
NPI:1700479482
Name:JACKSON, KATHRYN M (RDN)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3172 MORGANFORD RD APT 208
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-1965
Mailing Address - Country:US
Mailing Address - Phone:317-489-2263
Mailing Address - Fax:
Practice Address - Street 1:3172 MORGANFORD RD APT 208
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63116-1965
Practice Address - Country:US
Practice Address - Phone:317-489-2263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-14
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered