Healthcare Provider Details

I. General information

NPI: 1215889407
Provider Name (Legal Business Name): JASON DWIGHT BERNARD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2026
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4105 N WATER TOWER PL
MOUNT VERNON IL
62864-6296
US

IV. Provider business mailing address

4105 N WATER TOWER PL
MOUNT VERNON IL
62864-6296
US

V. Phone/Fax

Practice location:
  • Phone: 618-244-9495
  • Fax:
Mailing address:
  • Phone: 618-244-9495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.035119
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: