Provider Demographics
NPI:1982807715
Name:JACKSON, TRACIE LEE (RDN, LMNT, CDCES)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:LEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RDN, LMNT, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 127
Mailing Address - Street 2:
Mailing Address - City:HERMAN
Mailing Address - State:NE
Mailing Address - Zip Code:68029-0127
Mailing Address - Country:US
Mailing Address - Phone:402-456-7876
Mailing Address - Fax:
Practice Address - Street 1:1440 SW 3RD AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-6513
Practice Address - Country:US
Practice Address - Phone:352-402-5295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE347133V00000X
FL12865133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE347OtherRD LMNT CDE LICENSE