Provider Demographics
NPI:1689007551
Name:BUTT, JILLIAN RUTH (RD)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:RUTH
Last Name:BUTT
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 1:2235 ASHLEY CROSSING DR
Mailing Address - Street 2:APARTMENT 8H
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5779
Mailing Address - Country:US
Mailing Address - Phone:267-566-0983
Mailing Address - Fax:
Practice Address - Street 1:9330 MEDICAL PLAZA DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9104
Practice Address - Country:US
Practice Address - Phone:843-847-4973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-15
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC963133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered