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General NPI Number Information
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NPI Number | 1124377395
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Entity Type | Individual
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Provider Name | JADE N. MANCZUK RD, LD
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Gender | Female
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Dates
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Enumeration Date | 09/04/2012
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Last Update Date | 09/04/2012
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Provider Practice Location Address
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Address Line | 3231 S. NATIONAL SUITE 430
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City | SPRINGFIELD
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State | MO
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Zip | 65807
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Country | US
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Telephone | 417-888-5660
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Fax | 417-888-6793
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Provider Business Mailing Address
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Address Line | P.O. BOX 504274
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City | ST. LOUIS
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State | MO
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Zip | 63150-4274
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Country | US
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Telephone | 417-820-2000
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 2012024502
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License Number State | MO
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