Healthcare Provider Details

I. General information

NPI: 1013196682
Provider Name (Legal Business Name): COURTNEY M JAEGLE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2007
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 NE CRESCENT AVE
PEORIA IL
61606-1901
US

IV. Provider business mailing address

112 NE CRESCENT AVE
PEORIA IL
61606-1901
US

V. Phone/Fax

Practice location:
  • Phone: 309-672-4670
  • Fax: 309-672-4669
Mailing address:
  • Phone: 309-672-4670
  • Fax: 815-741-6303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0085003098
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: