Healthcare Provider Details

I. General information

NPI: 1194289983
Provider Name (Legal Business Name): JACKIE LENNETT PETERSON RD CDCES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACKIE HANNA LENNETT RD CDCES

II. Dates (important events)

Enumeration Date: 01/25/2019
Last Update Date: 08/14/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 ILENE DR
PLEASANT HILL CA
94523-2226
US

IV. Provider business mailing address

1888 BERKELEY WAY APT 306
BERKELEY CA
94703-1684
US

V. Phone/Fax

Practice location:
  • Phone: 925-819-0414
  • Fax:
Mailing address:
  • Phone: 925-819-0414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86100784
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: