Provider Demographics
NPI:1780061762
Name:JENERO, ROBERTA HELEN CLARKE (LDN)
Entity type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:HELEN CLARKE
Last Name:JENERO
Suffix:
Gender:F
Credentials:LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 N PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-2668
Mailing Address - Country:US
Mailing Address - Phone:847-508-7536
Mailing Address - Fax:
Practice Address - Street 1:980 N MICHIGAN AVE
Practice Address - Street 2:SUITE 1400
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4501
Practice Address - Country:US
Practice Address - Phone:312-988-4850
Practice Address - Fax:847-430-3108
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-29
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164001957133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1548498777OtherNPPES