Healthcare Provider Details

I. General information

NPI: 1316299456
Provider Name (Legal Business Name): JESSE LEE HENNEBERG APN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2012
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

IV. Provider business mailing address

201 E MADISON ST STE 328
SPRINGFIELD IL
62702-5131
US

V. Phone/Fax

Practice location:
  • Phone: 309-624-0629
  • Fax:
Mailing address:
  • Phone: 217-545-7731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number209009916
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number209009916
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: