Provider Demographics
NPI:1699223941
Name:POWELL, JACLYN (MS RD)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:MS RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 S MADISON ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-3968
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2020 E 29TH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99203-3917
Practice Address - Country:US
Practice Address - Phone:509-252-1366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-15
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
1095105OtherAND