Healthcare Provider Details

I. General information

NPI: 1043084528
Provider Name (Legal Business Name): JESSICA LYNN MANDRELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2023
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 BLOOMINGTON RD
CHAMPAIGN IL
61820-2101
US

IV. Provider business mailing address

819 BLOOMINGTON RD
CHAMPAIGN IL
61820-2101
US

V. Phone/Fax

Practice location:
  • Phone: 217-356-1558
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.028468
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: