Healthcare Provider Details

I. General information

NPI: 1578516605
Provider Name (Legal Business Name): JACQUELINE ROSE CHESTNUT RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 07/13/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 HOSPITAL DR COLISEUM MEDICAL CENTER
MACON GA
31208
US

IV. Provider business mailing address

134 OAKRIDGE DR
FORSYTH GA
31029-9588
US

V. Phone/Fax

Practice location:
  • Phone: 478-765-4189
  • Fax:
Mailing address:
  • Phone: 478-954-4185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD002040
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: