Healthcare Provider Details

I. General information

NPI: 1104103670
Provider Name (Legal Business Name): JESSICA M STEWART CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2011
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8940 N WOOD SAGE RD
PEORIA IL
61615-7822
US

IV. Provider business mailing address

8940 N WOOD SAGE RD
PEORIA IL
61615-7822
US

V. Phone/Fax

Practice location:
  • Phone: 309-243-3000
  • Fax: 309-243-3215
Mailing address:
  • Phone: 309-243-3000
  • Fax: 309-243-3215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number209009235
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number2029009235
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: