Provider Demographics
NPI:1013046242
Name:JEEP, SUSAN RUTH (DIETITIAN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:RUTH
Last Name:JEEP
Suffix:
Gender:F
Credentials:DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14575 W CRABAPPLE DR
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60083-9297
Mailing Address - Country:US
Mailing Address - Phone:847-360-2392
Mailing Address - Fax:847-782-3945
Practice Address - Street 1:1324 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-2161
Practice Address - Country:US
Practice Address - Phone:847-360-2392
Practice Address - Fax:847-782-3945
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered