Provider Demographics
NPI:1114746930
Name:DUST, JACOB (RD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:DUST
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 EAGLE PASS DR APT 318
Mailing Address - Street 2:
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-2056
Mailing Address - Country:US
Mailing Address - Phone:217-994-4033
Mailing Address - Fax:
Practice Address - Street 1:2401 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1188
Practice Address - Country:US
Practice Address - Phone:618-997-5311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-08
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered