Individual
JACQUELINE MARY SULLIVAN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
W3985 COUNTY ROAD NN, ELKHORN, WI 53121-4337
(262) 741-2145
(262) 741-2559
Mailing address
600 HIGHLAND AVE, COMPLIANCE MC 2433, MADISON, WI 53792-0001
(608) 662-0817
(608) 203-4544
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
Primary
685422
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1508-029
CERTIFIED DIETITIAN
WI
Enumeration date
01/26/2010
Last updated
10/08/2015
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