Provider Demographics
NPI:1053175109
Name:CHACON, JILLIAN (RD)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:CHACON
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 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:650-853-2961
Mailing Address - Fax:
Practice Address - Street 1:301 INDUSTRIAL RD
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-2603
Practice Address - Country:US
Practice Address - Phone:650-853-2961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-09
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86295151133VN1201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management