Healthcare Provider Details

I. General information

NPI: 1316606064
Provider Name (Legal Business Name): JILLIAN ROSE PEART RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2021
Last Update Date: 12/09/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5130 N US HIGHWAY 89
FLAGSTAFF AZ
86004-2837
US

IV. Provider business mailing address

927 W FOREST MEADOWS ST APT 320
FLAGSTAFF AZ
86001-8510
US

V. Phone/Fax

Practice location:
  • Phone: 928-773-2054
  • Fax:
Mailing address:
  • Phone: 714-393-8867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86117753
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: