Provider Demographics
NPI:1740647593
Name:KIELMANN, JAN (MS, CNS, IFMCP)
Entity type:Individual
Prefix:MR
First Name:JAN
Middle Name:
Last Name:KIELMANN
Suffix:
Gender:M
Credentials:MS, CNS, IFMCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10600 HIGHLAND SPRINGS AVE
Mailing Address - Street 2:
Mailing Address - City:CHERRY VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92223-5548
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 E OLIVE AVE STE F
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-5281
Practice Address - Country:US
Practice Address - Phone:909-810-0858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-25
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133NN1002X, 174H00000X
WANU 60611293133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No174H00000XOther Service ProvidersHealth Educator