Provider Demographics
NPI:1912109208
Name:ETHERTON, JENNIFER S (MS RD)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:S
Last Name:ETHERTON
Suffix:
Gender:F
Credentials:MS RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3198 PINEVIEW LN
Mailing Address - Street 2:
Mailing Address - City:METROPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62960-6600
Mailing Address - Country:US
Mailing Address - Phone:618-524-5798
Mailing Address - Fax:
Practice Address - Street 1:3198 PINEVIEW LN
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-6600
Practice Address - Country:US
Practice Address - Phone:618-524-5798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1188133V00000X
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered