Provider Demographics
NPI:1578870424
Name:MACGIBBON, JACQUELINE (RD LD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MACGIBBON
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 1:2000 HAMILTON ST
Mailing Address - Street 2:SUITE 303
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-3814
Mailing Address - Country:US
Mailing Address - Phone:215-564-4880
Mailing Address - Fax:215-564-4890
Practice Address - Street 1:2000 HAMILTON ST
Practice Address - Street 2:SUITE 303
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-3814
Practice Address - Country:US
Practice Address - Phone:215-564-4880
Practice Address - Fax:215-564-4890
Is Sole Proprietor?:No
Enumeration Date:2010-09-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN004129133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered