Provider Demographics
NPI:1023585999
Name:KIRSCHEN, JACLYN GAYLIS (MS, RD)
Entity type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:GAYLIS
Last Name:KIRSCHEN
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:MRS
Other - First Name:JACLYN
Other - Middle Name:BRITTANY
Other - Last Name:GAYLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD
Mailing Address - Street 1:PO BOX 910253
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92191-0253
Mailing Address - Country:US
Mailing Address - Phone:858-314-8469
Mailing Address - Fax:
Practice Address - Street 1:13112 CHAMBORD WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-5774
Practice Address - Country:US
Practice Address - Phone:619-251-4331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2020-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86076553133VN1201X
CA86076553133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
86076553OtherACADEMY NUTRITION DIETETICS