Provider Demographics
NPI:1558918177
Name:DZIUBA, JACQUELINE PATRICIA (RDN, LDN)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:PATRICIA
Last Name:DZIUBA
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751069
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:517 MOYE BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-2849
Practice Address - Country:US
Practice Address - Phone:252-744-2832
Practice Address - Fax:252-744-3457
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL005149133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ65387AOtherMEDICARE
NC2057JOtherBCBS OF NC