Healthcare Provider Details

I. General information

NPI: 1528251485
Provider Name (Legal Business Name): JENNIFER LYNN GUSTAFSON RD,LDN,CDE.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2007
Last Update Date: 10/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2233 W DIVISION ST
CHICAGO IL
60622-8151
US

IV. Provider business mailing address

2233 W DIVISION ST
CHICAGO IL
60622-8151
US

V. Phone/Fax

Practice location:
  • Phone: 312-770-2275
  • Fax: 312-633-5882
Mailing address:
  • Phone: 312-770-2275
  • Fax: 312-633-5882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number164002821
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: