Healthcare Provider Details

I. General information

NPI: 1841116142
Provider Name (Legal Business Name): EBONY JONAS-SANDERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 MEMORIAL DR STE 480
BELLEVILLE IL
62226-5372
US

IV. Provider business mailing address

6813 PELHAM MANOR DR
FAIRVIEW HEIGHTS IL
62208-2147
US

V. Phone/Fax

Practice location:
  • Phone: 618-257-5969
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number041540137
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: