Healthcare Provider Details

I. General information

NPI: 1952448466
Provider Name (Legal Business Name): SHERMA JACK-BRISSEAU NUTRI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 AUTH WAY
SUITLAND MD
20746-4207
US

IV. Provider business mailing address

2101 EAST JEFFERSON ST KAISER PERMANENTE
ROCKVILLE MD
20852-4908
US

V. Phone/Fax

Practice location:
  • Phone: 301-702-5250
  • Fax: 301-702-5262
Mailing address:
  • Phone: 301-816-7446
  • Fax: 301-816-7170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberN00207
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: