Provider Demographics
NPI:1154673747
Name:BELVILLE, JACLYNN EILEEN (RD, LD)
Entity Type:Individual
Prefix:MS
First Name:JACLYNN
Middle Name:EILEEN
Last Name:BELVILLE
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3355 GLENDALE AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-2426
Mailing Address - Country:US
Mailing Address - Phone:419-383-4585
Mailing Address - Fax:419-383-3112
Practice Address - Street 1:1125 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-8001
Practice Address - Country:US
Practice Address - Phone:419-383-4585
Practice Address - Fax:419-383-3112
Is Sole Proprietor?:No
Enumeration Date:2012-10-08
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD.7069133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0256301Medicaid