Provider Demographics
NPI:1093351041
Name:CLODFELTER-MASON, JILL SUZANNE (RD)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:SUZANNE
Last Name:CLODFELTER-MASON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6637 GRANNY SMITH LN
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-7503
Mailing Address - Country:US
Mailing Address - Phone:317-914-3049
Mailing Address - Fax:
Practice Address - Street 1:2031 EAGLEBROOKE PKWY
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:OH
Practice Address - Zip Code:45822-9396
Practice Address - Country:US
Practice Address - Phone:317-914-3049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37002740A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered