Healthcare Provider Details

I. General information

NPI: 1053175109
Provider Name (Legal Business Name): JILLIAN CHACON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2024
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 INDUSTRIAL RD
SAN CARLOS CA
94070-2603
US

IV. Provider business mailing address

325 DISTEL CIR
LOS ALTOS CA
94022-1408
US

V. Phone/Fax

Practice location:
  • Phone: 650-853-2961
  • Fax:
Mailing address:
  • Phone: 650-853-2961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number86295151
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: