Provider Demographics
NPI:1275247348
Name:DIPASQUALE, JENNIFER SUSAN (RDN, LDN, CDCES)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUSAN
Last Name:DIPASQUALE
Suffix:
Gender:F
Credentials:RDN, LDN, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 RUTLEDGE DR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:IL
Mailing Address - Zip Code:62656-1263
Mailing Address - Country:US
Mailing Address - Phone:217-732-7014
Mailing Address - Fax:
Practice Address - Street 1:1519 RUTLEDGE DR
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:IL
Practice Address - Zip Code:62656-1263
Practice Address - Country:US
Practice Address - Phone:217-732-7014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164-002539133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered