Provider Demographics
NPI:1366167702
Name:JACLYN POWELL NUTRITION, LLC
Entity type:Organization
Organization Name:JACLYN POWELL NUTRITION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/RD
Authorized Official - Prefix:
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, CEDRD-S
Authorized Official - Phone:720-341-5598
Mailing Address - Street 1:160 SPRING MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:KESWICK
Mailing Address - State:VA
Mailing Address - Zip Code:22947-3251
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:160 SPRING MEADOW LN
Practice Address - Street 2:
Practice Address - City:KESWICK
Practice Address - State:VA
Practice Address - Zip Code:22947-3251
Practice Address - Country:US
Practice Address - Phone:720-341-5598
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-07
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1699223941Medicaid