Healthcare Provider Details

I. General information

NPI: 1164038055
Provider Name (Legal Business Name): JASMINE CONYERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2020
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 E WINTER AVE
DANVILLE IL
61832-2295
US

IV. Provider business mailing address

2511A LEEPER DR
CHAMPAIGN IL
61822-6755
US

V. Phone/Fax

Practice location:
  • Phone: 217-651-6801
  • Fax:
Mailing address:
  • Phone: 217-512-0617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: