Provider Demographics
NPI:1437313152
Name:SUTTON, JACQUE LYNN
Entity type:Individual
Prefix:MRS
First Name:JACQUE
Middle Name:LYNN
Last Name:SUTTON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JACQUE
Other - Middle Name:LYNN
Other - Last Name:DU BOIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD, LD
Mailing Address - Street 1:3300 N. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-1562
Mailing Address - Country:US
Mailing Address - Phone:309-698-8190
Mailing Address - Fax:309-698-8303
Practice Address - Street 1:3300 N. MAIN ST.
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-1562
Practice Address - Country:US
Practice Address - Phone:309-698-8190
Practice Address - Fax:309-698-8303
Is Sole Proprietor?:No
Enumeration Date:2008-07-11
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.001022133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered