Healthcare Provider Details

I. General information

NPI: 1053249367
Provider Name (Legal Business Name): JESSICA KRUPKA CNS, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2026
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 E WESTMINSTER
LAKE FOREST IL
60045-1803
US

IV. Provider business mailing address

135 E WESTMINSTER
LAKE FOREST IL
60045-1803
US

V. Phone/Fax

Practice location:
  • Phone: 847-858-6804
  • Fax:
Mailing address:
  • Phone: 847-858-6804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number164.024005
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: