Provider Demographics
NPI:1053760553
Name:BOARDMAN, JACLYN S (RD)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:S
Last Name:BOARDMAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:S
Other - Last Name:REVELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:700 S PARK ST STE A
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1830
Mailing Address - Country:US
Mailing Address - Phone:608-260-2900
Mailing Address - Fax:608-260-2977
Practice Address - Street 1:700 S PARK ST STE A
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1830
Practice Address - Country:US
Practice Address - Phone:608-260-2900
Practice Address - Fax:608-260-2977
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2911-029133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1053760553Medicaid