Basic Information
| Provider Information | |||||||||
| NPI: | 1548652779 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BART | ||||||||
| FirstName: | JACLYN | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3333 E CAMELBACK RD | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850182322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029970484 | ||||||||
| FaxNumber: | 6022243358 | ||||||||
| Practice Location | |||||||||
| Address1: | 8415 N PIMA RD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852584480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805511057 | ||||||||
| FaxNumber: | 4805511059 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2015 | ||||||||
| LastUpdateDate: | 08/23/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 1079590 | AZ | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 989536 | 05 | AZ | MEDICAID |