Healthcare Provider Details

I. General information

NPI: 1861869687
Provider Name (Legal Business Name): JACLYN JANSEN AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2015
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 N MAPLE ST
EFFINGHAM IL
62401
US

IV. Provider business mailing address

1005 HEALTH CENTER DR STE 201
MATTOON IL
61938-4653
US

V. Phone/Fax

Practice location:
  • Phone: 217-347-7077
  • Fax: 217-347-7197
Mailing address:
  • Phone: 217-258-2581
  • Fax: 217-258-2216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number147001570
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: