Healthcare Provider Details

I. General information

NPI: 1689945339
Provider Name (Legal Business Name): LACI CHRISTINE JANKOWSKI APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2012
Last Update Date: 01/05/2021
Certification Date: 01/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 MCPHERSON AVE
MOUNT VERNON IL
62864-2831
US

IV. Provider business mailing address

490 W LEBANON ST
NASHVILLE IL
62263-1349
US

V. Phone/Fax

Practice location:
  • Phone: 618-241-1360
  • Fax: 618-241-1865
Mailing address:
  • Phone: 618-521-1657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number041-398735
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: