Healthcare Provider Details

I. General information

NPI: 1316483324
Provider Name (Legal Business Name): JODI LYNN CAWLEY LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2017
Last Update Date: 01/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2208 W. WILLOW KNOLLS RD
PEORIA IL
61614-1647
US

IV. Provider business mailing address

2208 W. WILLOW KNOLLS RD
PEORIA IL
61614-1647
US

V. Phone/Fax

Practice location:
  • Phone: 309-693-9600
  • Fax: 309-693-3616
Mailing address:
  • Phone: 309-693-9600
  • Fax: 309-693-3616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227.018221
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: