Individual
JILL THIEDE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD, RD
Contact information
Practice address
H200 MERCY CIRCLE, CAMP PENDLETON, CA 92055
(682) 885-7960
Mailing address
H200 MERCY CIRCLE, CAMP PENDLETON, CA 92055
Taxonomy
Speciality
Code
Description
License number
State
133VN1004X
Pediatric Nutrition Registered Dietitian
DT85560
TX
171000000X
Military Health Care Provider
—
—
208D00000X
General Practice Physician
Primary
2024034082
MO
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
DT85560
LICENSE
TX
Enumeration date
09/18/2018
Last updated
09/05/2024
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