Healthcare Provider Details

I. General information

NPI: 1023855566
Provider Name (Legal Business Name): PROMED PREFERRED IL 2 PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2024
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 MARKET PL STE 100
FAIRVIEW HEIGHTS IL
62208-2089
US

IV. Provider business mailing address

329 S OYSTER BAY RD # 2059
PLAINVIEW NY
11803-3301
US

V. Phone/Fax

Practice location:
  • Phone: 615-499-3165
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: THOMAS JOKERST
Title or Position: PRESIDENT
Credential: DO
Phone: 615-499-3165