Healthcare Provider Details

I. General information

NPI: 1568234524
Provider Name (Legal Business Name): JACOB TIMOTHY FEUCHT LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2023
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6615 N BIG HOLLOW RD
PEORIA IL
61615-2450
US

IV. Provider business mailing address

6615 N BIG HOLLOW RD
PEORIA IL
61615-2450
US

V. Phone/Fax

Practice location:
  • Phone: 309-692-6622
  • Fax: 309-692-6952
Mailing address:
  • Phone: 309-692-6622
  • Fax: 309-692-6952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150.112033
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: