Basic Information
| Provider Information | |||||||||
| NPI: | 1831771567 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHRADER | ||||||||
| FirstName: | JACKEE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 N ACADEMY AVE | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178224903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702716144 | ||||||||
| FaxNumber: | 5702716578 | ||||||||
| Practice Location | |||||||||
| Address1: | 560 PIERCE ST | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187045716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702832161 | ||||||||
| FaxNumber: | 5707140670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2021 | ||||||||
| LastUpdateDate: | 05/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 811421 | PA | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | DN001726 | PA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.