Healthcare Provider Details

I. General information

NPI: 1972952935
Provider Name (Legal Business Name): JESSICA REPAC R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2016
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 INGALLS DR
HARVEY IL
60426-3558
US

IV. Provider business mailing address

1 INGALLS DR
HARVEY IL
60426-3558
US

V. Phone/Fax

Practice location:
  • Phone: 708-915-5948
  • Fax:
Mailing address:
  • Phone: 708-915-5948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37002375A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164005982
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: