Healthcare Provider Details

I. General information

NPI: 1073285482
Provider Name (Legal Business Name): JACKLYN KAY STANLEY APRN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATIE STANLEY APRN, PMHNP-BC

II. Dates (important events)

Enumeration Date: 10/04/2021
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 E WALNUT ST
NOBLE IL
62868-1709
US

IV. Provider business mailing address

113 E WALNUT ST
NOBLE IL
62868-1709
US

V. Phone/Fax

Practice location:
  • Phone: 618-852-1395
  • Fax: 618-822-4196
Mailing address:
  • Phone: 618-514-8599
  • Fax: 618-822-4196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number277.005631
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: