Healthcare Provider Details

I. General information

NPI: 1710171699
Provider Name (Legal Business Name): JASON OWEN GREENLY BA, MHP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2007
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 E WASHINGTON ST
CHAMPAIGN IL
61820-3652
US

IV. Provider business mailing address

1510 W WHITE ST
CHAMPAIGN IL
61821-3114
US

V. Phone/Fax

Practice location:
  • Phone: 217-398-7785
  • Fax: 217-398-7787
Mailing address:
  • Phone: 217-355-7622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: