Provider Demographics
NPI:1538113576
Name:SCULLY, JENNIFER (RD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SCULLY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:VICKREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18789 2400 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:OHIO
Mailing Address - State:IL
Mailing Address - Zip Code:61349-9160
Mailing Address - Country:US
Mailing Address - Phone:815-289-0936
Mailing Address - Fax:
Practice Address - Street 1:600 E 1ST ST
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:IL
Practice Address - Zip Code:61362-1512
Practice Address - Country:US
Practice Address - Phone:815-664-1572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164003614133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered