Provider Demographics
NPI:1275333148
Name:DAVIS, JACQUELINE (RDN, LDN, IBCLC)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:
Credentials:RDN, LDN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:371 NC HIGHWAY 65
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-8881
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:371 NC HIGHWAY 65
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-8881
Practice Address - Country:US
Practice Address - Phone:336-342-8201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-18
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL-122675174N00000X
NC96253419133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN