Provider Demographics
NPI:1194381913
Name:JACKSON, PRESTON REID (RD)
Entity type:Individual
Prefix:
First Name:PRESTON
Middle Name:REID
Last Name:JACKSON
Suffix:
Gender:
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 FALLING LEAF TRL
Mailing Address - Street 2:
Mailing Address - City:SYLVA
Mailing Address - State:NC
Mailing Address - Zip Code:28779-9726
Mailing Address - Country:US
Mailing Address - Phone:910-214-0032
Mailing Address - Fax:
Practice Address - Street 1:526 FALLING LEAF TRL
Practice Address - Street 2:
Practice Address - City:SYLVA
Practice Address - State:NC
Practice Address - Zip Code:28779-9726
Practice Address - Country:US
Practice Address - Phone:910-214-0032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-16
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL005756133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered