Provider Demographics
NPI:1679923957
Name:THOLEN, JILLIAN THERESA (MS, RDN, LD)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:THERESA
Last Name:THOLEN
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 MISSISSIPPI RIVER BLVD N APT 304
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-5621
Mailing Address - Country:US
Mailing Address - Phone:507-993-1801
Mailing Address - Fax:
Practice Address - Street 1:411 E HENNEPIN AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414
Practice Address - Country:US
Practice Address - Phone:507-993-1801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2018-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3710133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered