Provider Demographics
NPI:1235650458
Name:ROLLER, JACQUELINE (RDN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:ROLLER
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3863 WEAVER RD
Mailing Address - Street 2:
Mailing Address - City:BELGRADE
Mailing Address - State:MT
Mailing Address - Zip Code:59714-8216
Mailing Address - Country:US
Mailing Address - Phone:406-589-7249
Mailing Address - Fax:
Practice Address - Street 1:80 N BROADWAY
Practice Address - Street 2:
Practice Address - City:BELGRADE
Practice Address - State:MT
Practice Address - Zip Code:59714-3701
Practice Address - Country:US
Practice Address - Phone:406-589-7249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-28
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-NUTR-LIC-51033133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered