Provider Demographics
NPI:1104488998
Name:KING, JILL MARIE (RDN,LD,CDE)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE
Last Name:KING
Suffix:
Gender:F
Credentials:RDN,LD,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4208 DRIFTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76309-1011
Mailing Address - Country:US
Mailing Address - Phone:940-704-2853
Mailing Address - Fax:
Practice Address - Street 1:920 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:TX
Practice Address - Zip Code:76384-3196
Practice Address - Country:US
Practice Address - Phone:940-553-2862
Practice Address - Fax:940-553-2967
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT02529133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered