Provider Demographics
NPI:1376920645
Name:DAVIS, JENNIFER (MS, RD, LDN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:HEW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN
Mailing Address - Street 1:800 E CARPENTER ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62769-1000
Mailing Address - Country:US
Mailing Address - Phone:217-544-6464
Mailing Address - Fax:217-757-6050
Practice Address - Street 1:400 N 9TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62769-1000
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-0130
Is Sole Proprietor?:No
Enumeration Date:2015-05-06
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
IL164005837133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered