Healthcare Provider Details

I. General information

NPI: 1245825223
Provider Name (Legal Business Name): JILLIAN PATE MS, RD, CSR, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2021
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 COFFMAN ST
BARBOURSVILLE WV
25504-2023
US

IV. Provider business mailing address

1811 COFFMAN ST
BARBOURSVILLE WV
25504-2023
US

V. Phone/Fax

Practice location:
  • Phone: 304-617-4067
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number969
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: