Basic Information
| Provider Information | |||||||||
| NPI: | 1952067621 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLON | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RDN, LDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1107 COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623012600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172238400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 324 S 14TH ST | ||||||||
| Address2: | |||||||||
| City: | ST CHARLES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601742511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107494555 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2021 | ||||||||
| LastUpdateDate: | 09/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 164.008463 | IL | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 164.008463 | 01 | IL | ILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION | OTHER |