Healthcare Provider Details

I. General information

NPI: 1689923013
Provider Name (Legal Business Name): JACOB E MEFFORD PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2012
Last Update Date: 01/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 NE GLEN OAK AVE
PEORIA IL
61636-0001
US

IV. Provider business mailing address

DEPT 960347
OKLAHOMA CITY OK
73196-0347
US

V. Phone/Fax

Practice location:
  • Phone: 309-672-5522
  • Fax:
Mailing address:
  • Phone: 800-684-0062
  • Fax: 405-844-1794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085004403
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: