Provider Demographics
NPI:1528197308
Name:HUMPHREY, JEANNINE DANIELLE (NT)
Entity Type:Individual
Prefix:MRS
First Name:JEANNINE
Middle Name:DANIELLE
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:NT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 WESTPORT DR
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60431-4939
Mailing Address - Country:US
Mailing Address - Phone:815-791-9157
Mailing Address - Fax:815-207-7828
Practice Address - Street 1:216 WESTPORT DR
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60431-4939
Practice Address - Country:US
Practice Address - Phone:815-791-9157
Practice Address - Fax:815-207-7828
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164003156133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist