Healthcare Provider Details

I. General information

NPI: 1922682822
Provider Name (Legal Business Name): JACKSONVILLE IL WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2021
Last Update Date: 05/07/2021
Certification Date: 05/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 W WALNUT ST STE D
JACKSONVILLE IL
62650-1153
US

IV. Provider business mailing address

1329 W COLLEGE AVE
JACKSONVILLE IL
62650-2216
US

V. Phone/Fax

Practice location:
  • Phone: 217-279-5815
  • Fax: 217-279-5816
Mailing address:
  • Phone: 217-204-8081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. KATHERINE S. O'NEIL
Title or Position: OWNER
Credential: FNP
Phone: 217-204-8081