Provider Demographics
NPI:1174635106
Name:MEYER, JANE A (MNT)
Entity Type:Individual
Prefix:MRS
First Name:JANE
Middle Name:A
Last Name:MEYER
Suffix:
Gender:F
Credentials:MNT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2560 24TH ST #102
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201
Mailing Address - Country:US
Mailing Address - Phone:309-788-0014
Mailing Address - Fax:309-779-3953
Practice Address - Street 1:2560 24TH ST #102
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201
Practice Address - Country:US
Practice Address - Phone:309-788-0014
Practice Address - Fax:309-779-3953
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered133N00000XDietary & Nutritional Service ProvidersNutritionist
Not Answered133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK27305Medicare ID - Type Unspecified