Healthcare Provider Details

I. General information

NPI: 1710256631
Provider Name (Legal Business Name): JESSICA R MISKELL INDEPENDENT APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JESSICA R KUYKENDALL-TAYLOR APN

II. Dates (important events)

Enumeration Date: 12/21/2011
Last Update Date: 02/04/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 W MADISON ST
OTTAWA IL
61350-2819
US

IV. Provider business mailing address

218 W MADISON ST
OTTAWA IL
61350-2819
US

V. Phone/Fax

Practice location:
  • Phone: 815-431-1122
  • Fax: 877-503-2851
Mailing address:
  • Phone: 815-431-1122
  • Fax: 877-503-2851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number209009286
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number209009286
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number277000895
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209009286
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number277000895
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number209009286
License Number StateIL
# 7
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number277000895
License Number StateIL
# 8
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number277000895
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: