Provider Demographics
NPI:1003300419
Name:MCLEAN, JILLIAN MANCHA (RD, LD)
Entity type:Individual
Prefix:MS
First Name:JILLIAN
Middle Name:MANCHA
Last Name:MCLEAN
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 1:524 ANASAZI CT
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-1271
Mailing Address - Country:US
Mailing Address - Phone:956-645-9716
Mailing Address - Fax:
Practice Address - Street 1:524 ANASAZI CT
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-1271
Practice Address - Country:US
Practice Address - Phone:956-645-9716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-19
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT82378133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty