Healthcare Provider Details

I. General information

NPI: 1437770393
Provider Name (Legal Business Name): JEANNETTE GARDNER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2020
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NE GLEN OAK AVE
PEORIA IL
61637
US

IV. Provider business mailing address

530 NE GLEN OAK AVE
PEORIA IL
61637
US

V. Phone/Fax

Practice location:
  • Phone: 309-655-2000
  • Fax:
Mailing address:
  • Phone: 502-852-8696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125080868
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125080868
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: