Healthcare Provider Details

I. General information

NPI: 1023585999
Provider Name (Legal Business Name): JACLYN GAYLIS KIRSCHEN MS, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JACLYN BRITTANY GAYLIS MS, RD

II. Dates (important events)

Enumeration Date: 10/30/2018
Last Update Date: 09/05/2020
Certification Date: 09/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13112 CHAMBORD WAY
SAN DIEGO CA
92130-5774
US

IV. Provider business mailing address

PO BOX 910253
SAN DIEGO CA
92191-0253
US

V. Phone/Fax

Practice location:
  • Phone: 619-251-4331
  • Fax:
Mailing address:
  • Phone: 858-314-8469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number86076553
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86076553
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: