Healthcare Provider Details

I. General information

NPI: 1679612121
Provider Name (Legal Business Name): JESSIE M GEBERT RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8701 BROADWAY
MERRILLVILLE IN
46410-7035
US

IV. Provider business mailing address

11504 W 134TH CT APT C
CEDAR LAKE IN
46303-2107
US

V. Phone/Fax

Practice location:
  • Phone: 219-738-5888
  • Fax: 219-738-6620
Mailing address:
  • Phone: 219-374-4955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37000353A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: