Provider Demographics
NPI:1194289983
Name:PETERSON, JACKIE LENNETT (RD CDCES)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:LENNETT
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RD CDCES
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:HANNA
Other - Last Name:LENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD CDCES
Mailing Address - Street 1:1888 BERKELEY WAY APT 306
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-1684
Mailing Address - Country:US
Mailing Address - Phone:925-819-0414
Mailing Address - Fax:
Practice Address - Street 1:213 ILENE DR
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-2226
Practice Address - Country:US
Practice Address - Phone:925-819-0414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-25
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86100784133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered