Provider Demographics
NPI:1780723585
Name:GLEW, JACQUELINE TOBINSON (RD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:TOBINSON
Last Name:GLEW
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5230 OLD ORCHARD RD
Mailing Address - Street 2:C/O BLOCK CENTER FOR INTEGRATIVE CANCER TREATMENT
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-1034
Mailing Address - Country:US
Mailing Address - Phone:847-492-3040
Mailing Address - Fax:847-505-0822
Practice Address - Street 1:5230 OLD ORCHARD RD
Practice Address - Street 2:C/O BLOCK CENTER FOR INTEGRATIVE CANCER TREATMENT
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-1034
Practice Address - Country:US
Practice Address - Phone:847-492-3040
Practice Address - Fax:847-505-0822
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164004220133V00000X, 133VN1006X, 133N00000X, 132700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No132700000XDietary & Nutritional Service ProvidersDietary Manager
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212041Medicare ID - Type UnspecifiedMEDICARE GROUP #
ILK19542Medicare ID - Type Unspecified