Provider Demographics
NPI:1679612121
Name:GEBERT, JESSIE M (RD)
Entity Type:Individual
Prefix:MS
First Name:JESSIE
Middle Name:M
Last Name:GEBERT
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 1:11504 W 134TH CT
Mailing Address - Street 2:APT C
Mailing Address - City:CEDAR LAKE
Mailing Address - State:IN
Mailing Address - Zip Code:46303-2107
Mailing Address - Country:US
Mailing Address - Phone:219-374-4955
Mailing Address - Fax:
Practice Address - Street 1:8701 BROADWAY
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7035
Practice Address - Country:US
Practice Address - Phone:219-738-5888
Practice Address - Fax:219-738-6620
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37000353A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN189450Medicare ID - Type UnspecifiedMEDICAL NUTRITION THERAPY