Healthcare Provider Details

I. General information

NPI: 1912100173
Provider Name (Legal Business Name): JENNIFER YANCEY RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

GREAT RIVER MEDICAL CENTER CENTER FOR REHABILITATION 1401 W. AGENCY RD.
WEST BURLINGTON IA
52655
US

IV. Provider business mailing address

1007 MONTICELLO DR
BURLINGTON IA
52601-8663
US

V. Phone/Fax

Practice location:
  • Phone: 319-768-4100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number01619
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: