Basic Information
Provider Information | |||||||||
NPI: | 1649272659 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JANSSEN | ||||||||
FirstName: | GEORGIA | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS RD LDN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SCHREACKE | ||||||||
OtherFirstName: | GEORGIA | ||||||||
OtherMiddleName: | A | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1005 BROADWAY ST | ||||||||
Address2: |   | ||||||||
City: | QUINCY | ||||||||
State: | IL | ||||||||
PostalCode: | 623012834 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2172238400 | ||||||||
FaxNumber: | 2172239716 | ||||||||
Practice Location | |||||||||
Address1: | 1005 BROADWAY ST | ||||||||
Address2: |   | ||||||||
City: | QUINCY | ||||||||
State: | IL | ||||||||
PostalCode: | 623012834 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2172238400 | ||||||||
FaxNumber: | 2172239716 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/10/2005 | ||||||||
LastUpdateDate: | 08/17/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 164-000168 | IL | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   | 133V00000X | 2004029301 | MO | N |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
ID Information
ID | Type | State | Issuer | Description | GJ1068001 | 01 | IL | AMERICAN SPECIALTY HEALTH | OTHER | 00132009 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER | 075113 | 01 | IL | QUINCY HEALTH CARE MGMT. | OTHER | 002410837 | 01 | IL | UNITED HEALTH CARE | OTHER |