Healthcare Provider Details

I. General information

NPI: 1578870424
Provider Name (Legal Business Name): JACQUELINE MACGIBBON RD LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2010
Last Update Date: 09/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 HAMILTON ST SUITE 303
PHILADELPHIA PA
19130-3814
US

IV. Provider business mailing address

2000 HAMILTON ST SUITE 303
PHILADELPHIA PA
19130-3814
US

V. Phone/Fax

Practice location:
  • Phone: 215-564-4880
  • Fax: 215-564-4890
Mailing address:
  • Phone: 215-564-4880
  • Fax: 215-564-4890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN004129
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: