Provider Demographics
NPI:1952475063
Name:BREYEN, JILL MARIA (RD,LD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:MARIA
Last Name:BREYEN
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 497
Mailing Address - Street 2:
Mailing Address - City:REDLAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56671-0497
Mailing Address - Country:US
Mailing Address - Phone:218-679-3912
Mailing Address - Fax:218-679-0181
Practice Address - Street 1:HWY 1
Practice Address - Street 2:
Practice Address - City:REDLAKE
Practice Address - State:MN
Practice Address - Zip Code:56671-0497
Practice Address - Country:US
Practice Address - Phone:218-679-3912
Practice Address - Fax:218-679-0181
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2050133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2050OtherDIETETICS
MN240206Medicare Oscar/Certification
MN2050OtherDIETETICS
MN8HBE87Medicare PIN