Healthcare Provider Details

I. General information

NPI: 1972410918
Provider Name (Legal Business Name): JASMINE T WILLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 CREEKVIEW BLVD
COVINGTON GA
30016-3084
US

IV. Provider business mailing address

537 CENTRAL PARKWAY RD
WOODSTOCK IL
60098-2660
US

V. Phone/Fax

Practice location:
  • Phone: 224-423-8892
  • Fax:
Mailing address:
  • Phone: 224-423-8892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number14619682
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: