Healthcare Provider Details

I. General information

NPI: 1255866448
Provider Name (Legal Business Name): JONATHAN AUBRY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2017
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 TRINITY LN
BLOOMINGTON IL
61704-8111
US

IV. Provider business mailing address

611 W PARK ST
URBANA IL
61801-2501
US

V. Phone/Fax

Practice location:
  • Phone: 309-661-6414
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036157079
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: