Healthcare Provider Details

I. General information

NPI: 1598413551
Provider Name (Legal Business Name): JACQUELYN HACKETT RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2022
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 COLORADO AVE STE 100E
SANTA MONICA CA
90404-5535
US

IV. Provider business mailing address

2450 COLORADO AVE STE 100E
SANTA MONICA CA
90404-5535
US

V. Phone/Fax

Practice location:
  • Phone: 626-353-7606
  • Fax:
Mailing address:
  • Phone: 626-353-7606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86100274
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: