Provider Demographics
NPI:1386453975
Name:GLIEDT, JACLYN (RD)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:GLIEDT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 ROBERTSON ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-3026
Mailing Address - Country:US
Mailing Address - Phone:417-489-1771
Mailing Address - Fax:
Practice Address - Street 1:930 ROBERTSON ST
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-3026
Practice Address - Country:US
Practice Address - Phone:417-489-1771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-07
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3177-29133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered