Healthcare Provider Details

I. General information

NPI: 1427802545
Provider Name (Legal Business Name): CONNECT WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2024
Last Update Date: 04/17/2024
Certification Date: 04/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2416 E WASHINGTON ST STE G
BLOOMINGTON IL
61704-1612
US

IV. Provider business mailing address

2506 KAITLYN DR
BLOOMINGTON IL
61704-3487
US

V. Phone/Fax

Practice location:
  • Phone: 309-261-1102
  • Fax:
Mailing address:
  • Phone: 309-261-1102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER GIBB
Title or Position: APRN, OWNER, DIRECTOR
Credential: APN, FNP-BC, PMHNP
Phone: 309-261-1102