Healthcare Provider Details

I. General information

NPI: 1669303731
Provider Name (Legal Business Name): JACEY MELISSA THELEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

838 W GLEN AVE
PEORIA IL
61614-4882
US

IV. Provider business mailing address

201 E NORTH LAKEVIEW DR
EAST PEORIA IL
61611-1050
US

V. Phone/Fax

Practice location:
  • Phone: 309-244-1655
  • Fax:
Mailing address:
  • Phone: 309-922-6720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.037106
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: