Provider Demographics
NPI:1801565981
Name:SHACKELFORD, JAMIE VANESSA (RD)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:VANESSA
Last Name:SHACKELFORD
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 1:31 NEW BOSTON CT
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-4344
Mailing Address - Country:US
Mailing Address - Phone:925-890-2225
Mailing Address - Fax:
Practice Address - Street 1:31 NEW BOSTON CT
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526-4344
Practice Address - Country:US
Practice Address - Phone:925-890-2225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA894935133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered