Healthcare Provider Details

I. General information

NPI: 1447949714
Provider Name (Legal Business Name): JADEYN LACEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2023
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1336 E EMPIRE ST
BLOOMINGTON IL
61701-3420
US

IV. Provider business mailing address

2412 E WASHINGTON ST STE 4A
BLOOMINGTON IL
61704-1613
US

V. Phone/Fax

Practice location:
  • Phone: 309-863-5454
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number041.440517
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number041.440517
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.440517
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: