Provider Demographics
NPI:1265053425
Name:NYBAKKEN, JILLIAN ELISE (RDN)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:ELISE
Last Name:NYBAKKEN
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11021 MEYERS DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-6892
Mailing Address - Country:US
Mailing Address - Phone:818-464-8223
Mailing Address - Fax:
Practice Address - Street 1:11801 PIERCE ST STE 200
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-4400
Practice Address - Country:US
Practice Address - Phone:951-750-0085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-29
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86094662133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered