Healthcare Provider Details

I. General information

NPI: 1922951219
Provider Name (Legal Business Name): JENNIFER MICHELLE MAZANEK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 E MCCORD ST
CENTRALIA IL
62801-3345
US

IV. Provider business mailing address

1003 E MCCORD ST
CENTRALIA IL
62801-3345
US

V. Phone/Fax

Practice location:
  • Phone: 618-436-6633
  • Fax:
Mailing address:
  • Phone: 618-436-6633
  • Fax: 618-436-6633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209035018
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: