Healthcare Provider Details

I. General information

NPI: 1619122835
Provider Name (Legal Business Name): JEANIE L BURKE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2008
Last Update Date: 12/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7177 CRIMSON RIDGE DR
ROCKFORD IL
61107-6235
US

IV. Provider business mailing address

2846 HEDGE CLIFF DR
ROCKFORD IL
61114-7403
US

V. Phone/Fax

Practice location:
  • Phone: 815-227-9900
  • Fax: 815-397-8070
Mailing address:
  • Phone: 815-877-8696
  • Fax: 815-877-8691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164001719
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: