Provider Demographics
NPI:1861614786
Name:JACKSON, JOHNNIE LAMM (MS, RD, LDN)
Entity type:Individual
Prefix:MRS
First Name:JOHNNIE
Middle Name:LAMM
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1572
Mailing Address - Street 2:
Mailing Address - City:BUIES CREEK
Mailing Address - State:NC
Mailing Address - Zip Code:27506-1572
Mailing Address - Country:US
Mailing Address - Phone:910-814-2909
Mailing Address - Fax:910-893-2167
Practice Address - Street 1:1785 KEITH HILLS ROAD
Practice Address - Street 2:
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546
Practice Address - Country:US
Practice Address - Phone:910-814-2909
Practice Address - Fax:910-893-2167
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL000862133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered