Provider Demographics
NPI:1063089555
Name:JACK, KELSEY (NTP)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:JACK
Suffix:
Gender:F
Credentials:NTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8507 WILD TRCE
Mailing Address - Street 2:
Mailing Address - City:GARDEN RIDGE
Mailing Address - State:TX
Mailing Address - Zip Code:78266-2219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8507 WILD TRCE
Practice Address - Street 2:
Practice Address - City:GARDEN RIDGE
Practice Address - State:TX
Practice Address - Zip Code:78266-2219
Practice Address - Country:US
Practice Address - Phone:210-854-1363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education