Provider Demographics
NPI:1811384639
Name:TILLMES, JACQLENE NICHOLLE (RD, CDN, CNSC)
Entity Type:Individual
Prefix:MS
First Name:JACQLENE
Middle Name:NICHOLLE
Last Name:TILLMES
Suffix:
Gender:F
Credentials:RD, CDN, CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 E ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2306
Mailing Address - Country:US
Mailing Address - Phone:315-464-8435
Mailing Address - Fax:
Practice Address - Street 1:725 IRVING AVE
Practice Address - Street 2:SUITE 504
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1603
Practice Address - Country:US
Practice Address - Phone:315-464-8435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-20
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007796133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered