Healthcare Provider Details

I. General information

NPI: 1346311008
Provider Name (Legal Business Name): SHARON DENISE JACKSON MS RD CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 BLUE HILLS AVE MATTAPAN COMMUNITY HEALTH CTR
MATTAPAN MA
02126
US

IV. Provider business mailing address

6 NEWCROFT CIRCLE
MATTAPAN MA
02126
US

V. Phone/Fax

Practice location:
  • Phone: 617-898-9052
  • Fax: 617-713-3438
Mailing address:
  • Phone: 617-296-3987
  • Fax: 617-713-3438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number1031
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: