Provider Demographics
NPI:1649376294
Name:CIARELLI, JACQUELINE JEAN (RD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:JEAN
Last Name:CIARELLI
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 1:4986 N ADAMS RD
Mailing Address - Street 2:STE D
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48306-5017
Mailing Address - Country:US
Mailing Address - Phone:313-336-8809
Mailing Address - Fax:
Practice Address - Street 1:4986 N ADAMS RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48306-5017
Practice Address - Country:US
Practice Address - Phone:248-475-4716
Practice Address - Fax:248-475-5777
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI712722133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN46110016Medicare ID - Type Unspecified