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NPI Code Detail

MEDICARE: JACLYNN MARIE NELSON RD, CDE

MEDICARE: JACLYNN MARIE NELSON RD, CDE
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1133V00000XRegistered Dietitian

General Provider Information

NPI Number : 1457365850
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACLYNN MARIE NELSON RD, CDE
Provider Business Mailing Address
First Line : 525 W BROWN RD
Second Line :
City : MESA
State : AZ
Zip : 85201-3202
Country : US
Telephone Number : 480-684-5040
Fax Number : 480-684-5026
Provider Business Practice Location Address
First Line : 525 W BROWN RD
Second Line :
City : MESA
State : AZ
Zip : 85201-3202
Country : US
Telephone Number : 480-684-5040
Fax Number : 480-684-5026
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/28/2006
Last Update Date : 01/24/2014

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