Healthcare Provider Details

I. General information

NPI: 1083160840
Provider Name (Legal Business Name): JAMMIE VICKERS APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 N DIVISION ST STE 701
MORRIS IL
60450-3120
US

IV. Provider business mailing address

1860 PAYSHERE CIR
CHICAGO IL
60674-1023
US

V. Phone/Fax

Practice location:
  • Phone: 815-942-5790
  • Fax:
Mailing address:
  • Phone: 630-545-6016
  • Fax: 630-545-4064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209.014771
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: