Provider Demographics
NPI:1124377395
Name:MANCZUK, JADE N (RD, LD)
Entity Type:Individual
Prefix:
First Name:JADE
Middle Name:N
Last Name:MANCZUK
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 504274
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-4274
Mailing Address - Country:US
Mailing Address - Phone:417-820-2000
Mailing Address - Fax:
Practice Address - Street 1:3231 S. NATIONAL
Practice Address - Street 2:SUITE 430
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807
Practice Address - Country:US
Practice Address - Phone:417-888-5660
Practice Address - Fax:417-888-6793
Is Sole Proprietor?:No
Enumeration Date:2012-09-04
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012024502133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO440552485OtherTRICARE