Provider Demographics
NPI:1770078107
Name:LIFESTYLE NUTRITION
Entity type:Organization
Organization Name:LIFESTYLE NUTRITION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NUTRITIONIST/OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:A
Authorized Official - Last Name:JACOBSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:845-379-4616
Mailing Address - Street 1:42 OAK ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07035-2434
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:42 OAK ST
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:NJ
Practice Address - Zip Code:07035-2434
Practice Address - Country:US
Practice Address - Phone:845-379-4616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Single Specialty