Healthcare Provider Details

I. General information

NPI: 1538113576
Provider Name (Legal Business Name): JENNIFER SCULLY RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER VICKREY

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 07/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 E 1ST ST
SPRING VALLEY IL
61362-1512
US

IV. Provider business mailing address

18789 2400 NORTH AVE
OHIO IL
61349-9160
US

V. Phone/Fax

Practice location:
  • Phone: 815-664-1572
  • Fax:
Mailing address:
  • Phone: 815-289-0936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164003614
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: