Healthcare Provider Details

I. General information

NPI: 1649272659
Provider Name (Legal Business Name): GEORGIA A JANSSEN MS RD LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. GEORGIA A SCHREACKE

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 08/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 BROADWAY ST
QUINCY IL
62301-2834
US

IV. Provider business mailing address

1005 BROADWAY ST
QUINCY IL
62301-2834
US

V. Phone/Fax

Practice location:
  • Phone: 217-223-8400
  • Fax: 217-223-9716
Mailing address:
  • Phone: 217-223-8400
  • Fax: 217-223-9716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164-000168
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2004029301
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: