Healthcare Provider Details

I. General information

NPI: 1043034838
Provider Name (Legal Business Name): JOSIE CATHRYN JEPSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2024
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 N MISSOURI AVE
PEORIA IL
61603-3105
US

IV. Provider business mailing address

17026 W PLEASANT GROVE RD
TRIVOLI IL
61569-9547
US

V. Phone/Fax

Practice location:
  • Phone: 309-308-3350
  • Fax:
Mailing address:
  • Phone: 309-397-3337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.010795
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: