Provider Demographics
NPI:1992950737
Name:JACKSON, LISA WILHELM (MS, RD, LDN, CNSC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:WILHELM
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS, RD, LDN, CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 ORLEANS ST
Mailing Address - Street 2:BLOOMBERG 9306
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21287-0010
Mailing Address - Country:US
Mailing Address - Phone:410-614-4486
Mailing Address - Fax:
Practice Address - Street 1:1800 ORLEANS ST
Practice Address - Street 2:BLOOMBERG 9306
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0010
Practice Address - Country:US
Practice Address - Phone:410-614-4486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-20
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164004668133V00000X
MDDX3435133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered