Provider Demographics
NPI:1649272659
Name:JANSSEN, GEORGIA A (MS RD LDN)
Entity type:Individual
Prefix:MRS
First Name:GEORGIA
Middle Name:A
Last Name:JANSSEN
Suffix:
Gender:F
Credentials:MS RD LDN
Other - Prefix:MRS
Other - First Name:GEORGIA
Other - Middle Name:A
Other - Last Name:SCHREACKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1005 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2834
Mailing Address - Country:US
Mailing Address - Phone:217-223-8400
Mailing Address - Fax:217-223-9716
Practice Address - Street 1:1005 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2834
Practice Address - Country:US
Practice Address - Phone:217-223-8400
Practice Address - Fax:217-223-9716
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164-000168133V00000X
MO2004029301133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILGJ1068001OtherAMERICAN SPECIALTY HEALTH
IL00132009OtherBLUE CROSS BLUE SHIELD
IL075113OtherQUINCY HEALTH CARE MGMT.
IL002410837OtherUNITED HEALTH CARE
IL00132009OtherBLUE CROSS BLUE SHIELD