Provider Demographics
NPI:1902315732
Name:JACKSON, JULIE (NC)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5792 DRAKES DR
Mailing Address - Street 2:
Mailing Address - City:DISCOVERY BAY
Mailing Address - State:CA
Mailing Address - Zip Code:94505-9380
Mailing Address - Country:US
Mailing Address - Phone:925-997-7101
Mailing Address - Fax:
Practice Address - Street 1:5792 DRAKES DR
Practice Address - Street 2:
Practice Address - City:DISCOVERY BAY
Practice Address - State:CA
Practice Address - Zip Code:94505-9380
Practice Address - Country:US
Practice Address - Phone:925-997-7101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANONE133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist