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General NPI Number Information
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NPI Number | 1346311008
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Entity Type | Individual
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Provider Name | SHARON DENISE JACKSON MS RD CDE
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Gender | Female
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Dates
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Enumeration Date | 11/13/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1425 BLUE HILLS AVE MATTAPAN COMMUNITY HEALTH CTR
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City | MATTAPAN
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State | MA
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Zip | 02126
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Country | US
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Telephone | 617-898-9052
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Fax | 617-713-3438
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Provider Business Mailing Address
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Address Line | 6 NEWCROFT CIRCLE
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City | MATTAPAN
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State | MA
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Zip | 02126
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Country | US
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Telephone | 617-296-3987
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Fax | 617-713-3438
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133N00000X
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Taxonomy Name | Nutritionist
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License Number | 1031
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License Number State | MA
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