Basic Information
| Provider Information | |||||||||
| NPI: | 1144427857 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOB | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | R.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 W UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618203981 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173668130 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1801 W WINDSOR RD | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618226217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173668144 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2007 | ||||||||
| LastUpdateDate: | 11/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 164.004493 | IL | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.