Provider Demographics
NPI:1588731061
Name:JICHA, LINDA DIANE (RD, CD, CDE)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:DIANE
Last Name:JICHA
Suffix:
Gender:F
Credentials:RD, CD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 ROBERTS LN
Mailing Address - Street 2:
Mailing Address - City:ABRAMS
Mailing Address - State:WI
Mailing Address - Zip Code:54101-9422
Mailing Address - Country:US
Mailing Address - Phone:920-785-3760
Mailing Address - Fax:
Practice Address - Street 1:2845 GREENBRIER RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6519
Practice Address - Country:US
Practice Address - Phone:920-288-3202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2321-029133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered