Provider Demographics
NPI:1154727402
Name:JACKOWSKI, JESSICA (RDN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:JACKOWSKI
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 1:2697 FLINT RIVER RD
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-9101
Mailing Address - Country:US
Mailing Address - Phone:734-635-4900
Mailing Address - Fax:
Practice Address - Street 1:2697 FLINT RIVER RD
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-9101
Practice Address - Country:US
Practice Address - Phone:734-635-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-14
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI979085133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered