Provider Demographics
NPI:1427181692
Name:BERTELSEN, JACQUELINE LYNN (RD, LD, LMNT)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LYNN
Last Name:BERTELSEN
Suffix:
Gender:F
Credentials:RD, LD, LMNT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2797
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-2797
Mailing Address - Country:US
Mailing Address - Phone:402-354-4230
Mailing Address - Fax:402-354-6171
Practice Address - Street 1:8111 DODGE ST STE 332
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4119
Practice Address - Country:US
Practice Address - Phone:402-354-5947
Practice Address - Fax:403-354-5651
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE345133V00000X
IAR011922133V00000X
IA00248133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAR011922OtherAMERICAN DIETETIC ASSOC
IA00248OtherIOWA DIETETIC LICENSE
NE345OtherNEBRASKA DIETETIC LICENSE