Individual
JACI ELIZABETH LAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
RD
Contact information
Practice address
432 N PLEASANT AVE, CENTRALIA, IL 62801-3006
(618) 436-8114
Mailing address
7843 COOLIDGE RD, OAKDALE, IL 62268-1415
(618) 978-3551
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
Primary
164.006872
IL
Other
Enumeration date
12/03/2019
Last updated
12/03/2019
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