Healthcare Provider Details

I. General information

NPI: 1962549790
Provider Name (Legal Business Name): JENIFER MARIE CHAMBLESS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W OAK ST
CARBONDALE IL
62901-1400
US

IV. Provider business mailing address

PO BOX 19639
SPRINGFIELD IL
62794-9639
US

V. Phone/Fax

Practice location:
  • Phone: 618-536-6621
  • Fax: 618-453-1102
Mailing address:
  • Phone: 217-545-8000
  • Fax: 844-470-2486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085001864
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085-001864
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: