Basic Information
| Provider Information | |||||||||
| NPI: | 1053760553 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REVELLO | ||||||||
| FirstName: | JACLYN | ||||||||
| MiddleName: | S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 S PARK ST STE A | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082602900 | ||||||||
| FaxNumber: | 6082602977 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 S PARK ST STE A | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082602900 | ||||||||
| FaxNumber: | 6082602977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2016 | ||||||||
| LastUpdateDate: | 11/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 2911-029 | WI | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 1053760553 | 05 | WI | MEDICAID |