Basic Information
| Provider Information | |||||||||
| NPI: | 1427132885 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COMERFORD | ||||||||
| FirstName: | JACKIE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 W. PARK ST. | ||||||||
| Address2: | BWPC | ||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173836792 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 LERNA RD S | ||||||||
| Address2: | |||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619389388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172585900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 04/13/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 164001482 | IL | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.