Healthcare Provider Details

I. General information

NPI: 1609152057
Provider Name (Legal Business Name): JENNIFER LEIGH SCALES FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2011
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 DEVINE DR
RIVERTON IL
62561-9627
US

IV. Provider business mailing address

37 DEVINE DR
RIVERTON IL
62561-9627
US

V. Phone/Fax

Practice location:
  • Phone: 217-891-3063
  • Fax: 217-891-3063
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209008285
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209008285
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: