Active NPI
Jaci Elizabeth Lake, RD
- Registered Dietitian
- Centralia, IL
National Provider Identifier
1235776816
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Registered Dietitian
- License
- 164.006872
- Practice address
- 432 N Pleasant Ave
Centralia, IL 62801-3006 - Phone
- (618) 436-8114
- NPI assigned
- Dec 3, 2019
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Registered Dietitian | 133V00000X | 164.006872 | IL | Primary |
Addresses
Primary practice location
432 N Pleasant Ave
Centralia, IL 62801-3006
Mailing address
7843 Coolidge Rd
Oakdale, IL 62268-1415
Phone (618) 978-3551
Other practice location 1
5 Good Samaritan Way
Mount Vernon, IL 62864-2402
Phone (618) 436-8114
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 164.006872 | IL | MD | Registered Dietitian |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1575331200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1575331200000",
"number": "1235776816",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "7843 COOLIDGE RD",
"city": "OAKDALE",
"state": "IL",
"postal_code": "622681415",
"telephone_number": "618-978-3551"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "432 N PLEASANT AVE",
"city": "CENTRALIA",
"state": "IL",
"postal_code": "628013006",
"telephone_number": "618-436-8114"
}
],
"practiceLocations": [
{
"address_1": "5 Good Samaritan Way",
"address_purpose": "LOCATION",
"city": "Mount Vernon",
"state": "IL",
"postal_code": "628642402",
"country_code": "US",
"telephone_number": "618-436-8114",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "LAKE",
"first_name": "JACI",
"middle_name": "ELIZABETH",
"credential": "RD",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2019-12-03",
"last_updated": "2019-12-03",
"status": "A"
},
"taxonomies": [
{
"code": "133V00000X",
"taxonomy_group": "",
"desc": "Dietitian, Registered",
"state": "IL",
"license": "164.006872",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Centralia, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 3, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.