Provider Demographics
NPI:1629462338
Name:CHAMBERLAIN, JACLYN (RDN)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:CHAMBERLAIN
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:
Other - Last Name:BURM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN
Mailing Address - Street 1:3100 W RAY RD
Mailing Address - Street 2:STE 201
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-2470
Mailing Address - Country:US
Mailing Address - Phone:480-207-5995
Mailing Address - Fax:480-550-8806
Practice Address - Street 1:3100 W RAY RD
Practice Address - Street 2:STE 201
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-2470
Practice Address - Country:US
Practice Address - Phone:480-207-5995
Practice Address - Fax:480-550-8806
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-20
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ962664133N00000X, 133NN1002X, 133V00000X, 133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric