Provider Demographics
NPI:1457716508
Name:SUMSKY, JACLYN (RD LDN)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:SUMSKY
Suffix:
Gender:F
Credentials:RD LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16609 BLACKFOOT DR
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-1501
Mailing Address - Country:US
Mailing Address - Phone:708-705-4881
Mailing Address - Fax:
Practice Address - Street 1:16609 BLACKFOOT DR
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-1501
Practice Address - Country:US
Practice Address - Phone:708-705-4881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-16
Last Update Date:2019-06-25
Deactivation Date:2019-06-13
Deactivation Code:
Reactivation Date:2019-06-21
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst