Provider Demographics
NPI:1528813342
Name:SCHULTZ, JESSICA ANN (RDN LDN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:SCHULTZ
Suffix:
Gender:F
Credentials:RDN LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-2431
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1706 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-2431
Practice Address - Country:US
Practice Address - Phone:217-781-3301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164008865133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered