Healthcare Provider Details

I. General information

NPI: 1346693223
Provider Name (Legal Business Name): JASPER COUNTY HEALTH DEPARTMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2016
Last Update Date: 12/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 EDWARDS ST
NEWTON IL
62448-1736
US

IV. Provider business mailing address

106 EDWARDS ST
NEWTON IL
62448-1736
US

V. Phone/Fax

Practice location:
  • Phone: 618-783-4154
  • Fax: 618-783-2339
Mailing address:
  • Phone: 618-783-4154
  • Fax: 618-783-2339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License NumberA01400001A
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberA01400001A
License Number StateIL

VIII. Authorized Official

Name: JEANNIE JOHNSON
Title or Position: DIRECTOR OF BEHAVIORAL HEALTH
Credential: M.S., LCPC, CADC
Phone: 618-783-4154