Healthcare Provider Details

I. General information

NPI: 1780723585
Provider Name (Legal Business Name): JACQUELINE TOBINSON GLEW RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 03/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5230 OLD ORCHARD RD C/O BLOCK CENTER FOR INTEGRATIVE CANCER TREATMENT
SKOKIE IL
60077-1034
US

IV. Provider business mailing address

5230 OLD ORCHARD RD C/O BLOCK CENTER FOR INTEGRATIVE CANCER TREATMENT
SKOKIE IL
60077-1034
US

V. Phone/Fax

Practice location:
  • Phone: 847-492-3040
  • Fax: 847-505-0822
Mailing address:
  • Phone: 847-492-3040
  • Fax: 847-505-0822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164004220
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number164004220
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number164004220
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code132700000X
TaxonomyDietary Manager
License Number164004220
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: