MEDICARE: JACQUELINE R CLAYTON APN

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	363LF0000X	Family Nurse Practitioner	277000144	IL
2	363LF0000X	Family Nurse Practitioner	209-006100	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821019969
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE R CLAYTON APN

Provider Business Mailing Address
First Line	:	1005 HEALTH CENTER DR STE 201
Second Line	:
City	:	MATTOON
State	:	IL
Zip	:	61938-4693
Country	:	US
Telephone Number	:	217-238-6055
Fax Number	:

Provider Business Practice Location Address
First Line	:	1215 W MAIN ST
Second Line	:
City	:	SHELBYVILLE
State	:	IL
Zip	:	62565-1252
Country	:	US
Telephone Number	:	217-774-4305
Fax Number	:	217-774-4306

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

Provider Enumeration Date	:	07/22/2006
Last Update Date	:	01/15/2020

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