Provider Demographics
NPI:1336124791
Name:ROUP, JILL M (RD,CSO,CD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:M
Last Name:ROUP
Suffix:
Gender:F
Credentials:RD,CSO,CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7226
Mailing Address - Fax:920-445-7238
Practice Address - Street 1:1580 COMMANCHE AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-5751
Practice Address - Country:US
Practice Address - Phone:920-435-8326
Practice Address - Fax:920-430-4659
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1567133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered