MEDICARE: JACKIE ANNE NOVAK RD

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
1	133V00000X	Registered Dietitian	86376275

General Provider Information

NPI Number	:	1912865809
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKIE ANNE NOVAK RD

Provider Business Mailing Address
First Line	:	8388 COURT AVE STE 202
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21043-5203
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8388 COURT AVE STE 202
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21043-5203
Country	:	US
Telephone Number	:	443-355-7021
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/12/2026
Last Update Date	:	01/12/2026

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