Healthcare Provider Details

I. General information

NPI: 1881125565
Provider Name (Legal Business Name): JEEMIN EVERSOLE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 05/15/2023
Certification Date: 05/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 N MERCHANT ST
EFFINGHAM IL
62401-2128
US

IV. Provider business mailing address

PO BOX 665
EFFINGHAM IL
62401-0665
US

V. Phone/Fax

Practice location:
  • Phone: 217-342-7000
  • Fax: 217-342-7002
Mailing address:
  • Phone: 217-342-7000
  • Fax: 217-342-7002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041-405262
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209-015825
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: