Healthcare Provider Details

I. General information

NPI: 1477682854
Provider Name (Legal Business Name): JENNIFER LYNN MCCABE RD, LD, CLC, CD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 OSTEEN LN
CHATHAM IL
62629-5007
US

IV. Provider business mailing address

306 OSTEEN LN
CHATHAM IL
62629-5007
US

V. Phone/Fax

Practice location:
  • Phone: 217-280-0220
  • Fax: 217-483-6891
Mailing address:
  • Phone: 217-280-0220
  • Fax: 217-483-6891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: