Provider Demographics
NPI:1629107495
Name:FULAYTER, JODI ANNE (RD)
Entity Type:Individual
Prefix:MRS
First Name:JODI
Middle Name:ANNE
Last Name:FULAYTER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2902 CAMPBELL ST
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-6492
Mailing Address - Country:US
Mailing Address - Phone:708-261-3463
Mailing Address - Fax:815-744-2707
Practice Address - Street 1:2902 CAMPBELL ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6492
Practice Address - Country:US
Practice Address - Phone:708-261-3463
Practice Address - Fax:815-744-2707
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164003007133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09932114OtherBLUE CROSS BLUE SHIELD