Healthcare Provider Details

I. General information

NPI: 1417783713
Provider Name (Legal Business Name): JAMIE GILLETT RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2024
Last Update Date: 09/12/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E 9TH ST
PANA IL
62557-1785
US

IV. Provider business mailing address

793 E 2500 NORTH RD
MOWEAQUA IL
62550-8576
US

V. Phone/Fax

Practice location:
  • Phone: 217-562-2131
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.005648
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: