MEDICARE: JENNA LEE GILCREASE RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	975542	IN

General Provider Information

NPI Number	:	1649542762
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNA LEE GILCREASE RD

Provider Business Mailing Address
First Line	:	3965 N MERIDIAN ST
Second Line	:	#6D
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46208-4044
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3965 N MERIDIAN ST
Second Line	:	#6D
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46208-4044
Country	:	US
Telephone Number	:	317-308-9120
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2012
Last Update Date	:	02/06/2012

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