Provider Demographics
NPI:1790366078
Name:SCHWIESOW, JACOLYNN MARIE (RDN)
Entity Type:Individual
Prefix:
First Name:JACOLYNN
Middle Name:MARIE
Last Name:SCHWIESOW
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1244 PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-1247
Mailing Address - Country:US
Mailing Address - Phone:815-228-3388
Mailing Address - Fax:
Practice Address - Street 1:1244 PARK BLVD
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-1247
Practice Address - Country:US
Practice Address - Phone:815-228-3388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-18
Last Update Date:2021-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered