Healthcare Provider Details

I. General information

NPI: 1023948973
Provider Name (Legal Business Name): INK & IVY PSYCHIATRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 S MAIN ST
DIETERICH IL
62424-1128
US

IV. Provider business mailing address

113 E WALNUT ST
NOBLE IL
62868-1709
US

V. Phone/Fax

Practice location:
  • Phone: 618-852-1395
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JACKLYN STANLEY
Title or Position: PMHNP
Credential: APRN
Phone: 618-852-1395