Provider Demographics
NPI:1972651628
Name:SPANGLER, JILL
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:
Last Name:SPANGLER
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JILL
Other - Middle Name:ANN
Other - Last Name:KLOSS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:800 WHEELING AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN DALE
Mailing Address - State:WV
Mailing Address - Zip Code:26038-1660
Mailing Address - Country:US
Mailing Address - Phone:304-551-3555
Mailing Address - Fax:
Practice Address - Street 1:800 WHEELING AVE
Practice Address - Street 2:
Practice Address - City:GLEN DALE
Practice Address - State:WV
Practice Address - Zip Code:26038-1660
Practice Address - Country:US
Practice Address - Phone:304-551-3555
Practice Address - Fax:304-221-4526
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5917133V00000X
WV639133V00000X
133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
916493OtherDIETITIAN REGISTRY
WV1972651628Medicaid