Provider Demographics
NPI:1629453097
Name:GILLIGAN, JAMES KEVIN JR (RD, LD)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:KEVIN
Last Name:GILLIGAN
Suffix:JR
Gender:M
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6612 WINNEBAGO ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-1245
Mailing Address - Country:US
Mailing Address - Phone:314-537-0932
Mailing Address - Fax:
Practice Address - Street 1:501 LAKE LAND BLVD
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-5283
Practice Address - Country:US
Practice Address - Phone:217-258-3370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164006502133V00000X
MO2012036779133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered