Provider Demographics
NPI:1417783713
Name:GILLETT, JAMIE (RD)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:GILLETT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:793 E 2500 NORTH RD
Mailing Address - Street 2:
Mailing Address - City:MOWEAQUA
Mailing Address - State:IL
Mailing Address - Zip Code:62550-8576
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 E 9TH ST
Practice Address - Street 2:
Practice Address - City:PANA
Practice Address - State:IL
Practice Address - Zip Code:62557-1785
Practice Address - Country:US
Practice Address - Phone:217-562-2131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-12
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.005648133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered