Healthcare Provider Details

I. General information

NPI: 1265916167
Provider Name (Legal Business Name): JILL THIEDE MD, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 09/21/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

H200 MERCY CIRCLE
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

BLDG 41008 CAMP PENDLETON, CA
APO AA
92055
US

V. Phone/Fax

Practice location:
  • Phone: 682-885-7960
  • Fax:
Mailing address:
  • Phone: 760-725-8007
  • Fax: 760-725-6615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberDT85560
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2024034082
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: