MEDICARE: JESSICA GATLIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1225867021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA GATLIN

Provider Business Mailing Address
First Line	:	1206 RIDGE AVE
Second Line	:
City	:	COLLINSVILLE
State	:	IL
Zip	:	62234-4538
Country	:	US
Telephone Number	:	618-917-5063
Fax Number	:

Provider Business Practice Location Address
First Line	:	131 LINCOLN PLACE CT
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62221-5825
Country	:	US
Telephone Number	:	314-786-2870
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/30/2024
Last Update Date	:	07/30/2024

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