Healthcare Provider Details

I. General information

NPI: 1306380100
Provider Name (Legal Business Name): JAMIE LYNN NESNIDAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2016
Last Update Date: 12/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

452 N EOLA RD SUITE A
AURORA IL
60502-9612
US

IV. Provider business mailing address

2392 PUTNAM DR
NAPERVILLE IL
60565-3044
US

V. Phone/Fax

Practice location:
  • Phone: 630-999-0401
  • Fax: 630-423-9669
Mailing address:
  • Phone: 630-853-9280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-16-26554
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: