Healthcare Provider Details

I. General information

NPI: 1407847569
Provider Name (Legal Business Name): DAVID M JAHN PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 N STATE ST
MONTICELLO IL
61856-1151
US

IV. Provider business mailing address

1111 N STATE ST
MONTICELLO IL
61856-1151
US

V. Phone/Fax

Practice location:
  • Phone: 217-762-2115
  • Fax: 217-762-6165
Mailing address:
  • Phone: 217-762-2115
  • Fax: 217-762-6165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: