Provider Demographics
NPI:1912100173
Name:YANCEY, JENNIFER (RD, LD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:YANCEY
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 MONTICELLO DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52601-8663
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:GREAT RIVER MEDICAL CENTER CENTER FOR REHABILITATION
Practice Address - Street 2:1401 W. AGENCY RD.
Practice Address - City:WEST BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52655
Practice Address - Country:US
Practice Address - Phone:319-768-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01619133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI14204Medicare UPIN