Provider Demographics
NPI:1457808222
Name:KUBALA, JILLIAN ALEXANDRA (RD)
Entity Type:Individual
Prefix:MRS
First Name:JILLIAN
Middle Name:ALEXANDRA
Last Name:KUBALA
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 S COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:WESTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11977-1413
Mailing Address - Country:US
Mailing Address - Phone:631-871-9856
Mailing Address - Fax:
Practice Address - Street 1:38 S COUNTRY RD
Practice Address - Street 2:
Practice Address - City:WESTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11977-1413
Practice Address - Country:US
Practice Address - Phone:631-871-9856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86058432133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered