Healthcare Provider Details

I. General information

NPI: 1982888343
Provider Name (Legal Business Name): JAMIE LYNN FRED LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JAMIE LYNN CARTER LPN

II. Dates (important events)

Enumeration Date: 12/20/2007
Last Update Date: 12/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 GAS PLANT ROAD REA CLINIC-DUQUOIN
JOHNSTON CITY IL
62951
US

IV. Provider business mailing address

PO BOX 155 REA CLINIC
CHRISTOPHER IL
62822
US

V. Phone/Fax

Practice location:
  • Phone: 618-542-8702
  • Fax: 618-542-8792
Mailing address:
  • Phone: 618-724-2401
  • Fax: 618-724-4628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: