Provider Demographics
NPI:1356308928
Name:PLUSKOTA, JENELL A (BS RD)
Entity Type:Individual
Prefix:MS
First Name:JENELL
Middle Name:A
Last Name:PLUSKOTA
Suffix:
Gender:F
Credentials:BS RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 S DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-1359
Mailing Address - Country:US
Mailing Address - Phone:618-985-4278
Mailing Address - Fax:
Practice Address - Street 1:106 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:CARTERVILLE
Practice Address - State:IL
Practice Address - Zip Code:62918-1359
Practice Address - Country:US
Practice Address - Phone:618-985-4278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164004390133N00000X, 133V00000X, 133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN