Healthcare Provider Details

I. General information

NPI: 1164122974
Provider Name (Legal Business Name): JESSICA R THERIEN APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2023
Last Update Date: 09/26/2025
Certification Date: 09/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2122 TROY RD STE 130
EDWARDSVILLE IL
62025-2540
US

IV. Provider business mailing address

4600 MEMORIAL DR STE 360
BELLEVILLE IL
62226-5366
US

V. Phone/Fax

Practice location:
  • Phone: 618-800-4500
  • Fax:
Mailing address:
  • Phone: 618-222-7280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209026898
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: