Provider Demographics
NPI:1316606064
Name:PEART, JILLIAN ROSE (RDN)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:ROSE
Last Name:PEART
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 W FOREST MEADOWS ST APT 320
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-8510
Mailing Address - Country:US
Mailing Address - Phone:714-393-8867
Mailing Address - Fax:
Practice Address - Street 1:5130 N US HIGHWAY 89
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-2837
Practice Address - Country:US
Practice Address - Phone:928-773-2054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86117753133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered