Healthcare Provider Details

I. General information

NPI: 1932517232
Provider Name (Legal Business Name): MICHELE ERIN JAKACKI RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2014
Last Update Date: 12/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9601 INTERSTATE 630 # EXIT7 HEALTH MANAGEMENT
LITTLE ROCK AR
72205-7202
US

IV. Provider business mailing address

9601 INTERSTATE 630 # EXIT7 HEALTH MANAGEMENT
LITTLE ROCK AR
72205-7202
US

V. Phone/Fax

Practice location:
  • Phone: 501-202-1877
  • Fax:
Mailing address:
  • Phone: 501-202-1877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1490
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: