Provider Demographics
NPI:1629663513
Name:TYSON, JILLIAN QUIN (RD)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:QUIN
Last Name:TYSON
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 1:2003 FRANKELLA AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15221-1507
Mailing Address - Country:US
Mailing Address - Phone:570-618-5006
Mailing Address - Fax:
Practice Address - Street 1:2003 FRANKELLA AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15221-1507
Practice Address - Country:US
Practice Address - Phone:570-618-5006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-03
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1318133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered