Healthcare Provider Details

I. General information

NPI: 1396398582
Provider Name (Legal Business Name): JAELEN HULL RDN, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2019
Last Update Date: 07/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HAWKINS DR
IOWA CITY IA
52242-1009
US

IV. Provider business mailing address

605 CHASE CT
BOURBONNAIS IL
60914-5143
US

V. Phone/Fax

Practice location:
  • Phone: 319-356-1616
  • Fax:
Mailing address:
  • Phone: 815-683-5393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number097408
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: