Provider Demographics
NPI:1003423823
Name:LAIRD, JEANNE THERESE (RDN LDN)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:THERESE
Last Name:LAIRD
Suffix:
Gender:F
Credentials:RDN LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 FITNESS DR
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-9584
Mailing Address - Country:US
Mailing Address - Phone:815-936-6515
Mailing Address - Fax:815-936-6517
Practice Address - Street 1:100 FITNESS DR
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-9584
Practice Address - Country:US
Practice Address - Phone:815-936-6515
Practice Address - Fax:815-936-6517
Is Sole Proprietor?:No
Enumeration Date:2020-09-25
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.007610133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered