Provider Demographics
NPI:1134367477
Name:MCCANN, JILL TYLER (MS, RD, LD/N)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:TYLER
Last Name:MCCANN
Suffix:
Gender:F
Credentials:MS, RD, LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2344 3RD ST S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-4023
Mailing Address - Country:US
Mailing Address - Phone:904-874-5576
Mailing Address - Fax:904-513-9268
Practice Address - Street 1:2344 3RD ST S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-4023
Practice Address - Country:US
Practice Address - Phone:904-874-5576
Practice Address - Fax:904-513-9268
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-23
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND4745133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered