Provider Demographics
NPI:1740511104
Name:SULLIVAN, JACQUELINE MARY
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARY
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 HIGHLAND AVE
Mailing Address - Street 2:COMPLIANCE MC 2433
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53792-0001
Mailing Address - Country:US
Mailing Address - Phone:608-662-0817
Mailing Address - Fax:608-203-4544
Practice Address - Street 1:W3985 COUNTY ROAD NN
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-4337
Practice Address - Country:US
Practice Address - Phone:262-741-2145
Practice Address - Fax:262-741-2559
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-26
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
685422133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1508-029OtherCERTIFIED DIETITIAN