Provider Demographics
NPI:1891583043
Name:WEASE, JILLIAN MONTGOMERY (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:MONTGOMERY
Last Name:WEASE
Suffix:
Gender:
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1724 KENTON ST STE 2B
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240-1981
Mailing Address - Country:US
Mailing Address - Phone:270-632-4555
Mailing Address - Fax:270-632-4556
Practice Address - Street 1:1724 KENTON ST STE 2B
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-1981
Practice Address - Country:US
Practice Address - Phone:270-632-4555
Practice Address - Fax:270-632-4556
Is Sole Proprietor?:No
Enumeration Date:2025-04-28
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY265862133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered