Basic Information
| Provider Information | |||||||||
| NPI: | 1235207481 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GEORGE | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LYNNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RD LD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DUNBAR | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | LYNNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1200 6TH AVENUE NORTH | ||||||||
| Address2: | CENTRACARE CLINIC RIVER CAMPUS | ||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206567020 | ||||||||
| FaxNumber: | 3202555714 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 6TH AVENUE NORTH | ||||||||
| Address2: | CENTRACARE CLINIC RIVER CAMPUS | ||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206567020 | ||||||||
| FaxNumber: | 3202555714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2006 | ||||||||
| LastUpdateDate: | 10/10/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 887483 | MN | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | 2308 | MN | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.