Provider Demographics
NPI:1225776495
Name:CAMPBELL, JILL ANN (MS, RD, LD, CDE)
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:ANN
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MS, RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 WILLIAMSBURG CIR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-6672
Mailing Address - Country:US
Mailing Address - Phone:903-258-0357
Mailing Address - Fax:
Practice Address - Street 1:3593 E GRANDE BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75707-1400
Practice Address - Country:US
Practice Address - Phone:903-839-2585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
887653133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
133V00000XOtherCOMMISSION OF DIETETIC REGISTRATION
20420056OtherCERTIFICATION BOARD FOR DIABETES CARE AND EDUCATION