Provider Demographics
NPI:1922040369
Name:ROBILLIARD, JACQUELINE J (RD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:J
Last Name:ROBILLIARD
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 1:150 DRESDEN AVE
Mailing Address - Street 2:
Mailing Address - City:GARDINER
Mailing Address - State:ME
Mailing Address - Zip Code:04345-2615
Mailing Address - Country:US
Mailing Address - Phone:207-621-9337
Mailing Address - Fax:207-626-1214
Practice Address - Street 1:157 CAPITOL ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-6264
Practice Address - Country:US
Practice Address - Phone:207-621-9320
Practice Address - Fax:207-621-9322
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI576133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMT0529Medicare ID - Type Unspecified