Provider Demographics
NPI:1497104616
Name:TACIA, JILLIAN (RD)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:TACIA
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 1:25710 KELLY RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4959
Mailing Address - Country:US
Mailing Address - Phone:586-772-2600
Mailing Address - Fax:586-772-5289
Practice Address - Street 1:25710 KELLY RD
Practice Address - Street 2:SUITE 3
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4959
Practice Address - Country:US
Practice Address - Phone:586-772-2600
Practice Address - Fax:586-772-5289
Is Sole Proprietor?:No
Enumeration Date:2016-06-08
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P16170Medicare PIN