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General NPI Number Information
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NPI Number | 1699477109
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Entity Type | Individual
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Provider Name | BIANCHA JACKSON MHSC, RD
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Gender | Female
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Dates
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Enumeration Date | 03/20/2023
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Last Update Date | 03/20/2023
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Provider Practice Location Address
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Address Line | 5201 HAVERFORD AVE
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City | PHILADELPHIA
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State | PA
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Zip | 19139-1401
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Country | US
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Telephone | 215-471-2761
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Fax |
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Provider Business Mailing Address
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Address Line | 7 DUMONT CT
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City | LAWRENCEVILLE
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State | NJ
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Zip | 08648-1334
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Country | US
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Telephone | 609-902-0156
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Fax |
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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 | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 86096975
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License Number State |
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