Provider Demographics
NPI:1770569667
Name:NIELSEN, JACQUELYN JO (MS, RD, CDE)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:JO
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:MS, RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 HILLROSE DRIVE
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538
Mailing Address - Country:US
Mailing Address - Phone:970-622-9997
Mailing Address - Fax:970-667-8383
Practice Address - Street 1:1101 OAKRIDGE DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525
Practice Address - Country:US
Practice Address - Phone:970-622-9997
Practice Address - Fax:970-667-8383
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO708546133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP00241054OtherRAILROAD MEDICARE
COC 452618Medicare PIN