Provider Demographics
NPI:1407621170
Name:JACKSON, LAUREN ELIZABETH (RD)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:ELIZABETH
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 BEAR CREEK PKWY APT 1536
Mailing Address - Street 2:
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76039-5245
Mailing Address - Country:US
Mailing Address - Phone:972-217-5216
Mailing Address - Fax:
Practice Address - Street 1:2800 WILLIAM D TATE AVE STE 300
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-4326
Practice Address - Country:US
Practice Address - Phone:972-217-5216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-22
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered