Provider Demographics
NPI:1306312723
Name:MOORE, JILLIAN (LD, RDN)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LD, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25617 S HARRIS RD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:64034-8247
Mailing Address - Country:US
Mailing Address - Phone:816-830-9214
Mailing Address - Fax:
Practice Address - Street 1:25617 S HARRIS RD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MO
Practice Address - Zip Code:64034-8247
Practice Address - Country:US
Practice Address - Phone:816-830-9214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017036202133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered