Provider Demographics
NPI:1134834450
Name:CLARK, JILL MARIE (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:
Other - Last Name:SCHILLING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD, LD
Mailing Address - Street 1:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-1239
Mailing Address - Country:US
Mailing Address - Phone:573-248-5400
Mailing Address - Fax:573-248-5264
Practice Address - Street 1:6500 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6890
Practice Address - Country:US
Practice Address - Phone:573-406-5952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-20
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021046266133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered