Provider Demographics
NPI:1376165571
Name:HERR, JACILYN KAY T
Entity Type:Individual
Prefix:
First Name:JACILYN
Middle Name:KAY T
Last Name:HERR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 N MULLEN ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98406-3302
Mailing Address - Country:US
Mailing Address - Phone:253-414-2867
Mailing Address - Fax:
Practice Address - Street 1:721 FAWCETT AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-5502
Practice Address - Country:US
Practice Address - Phone:253-355-9866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist