Healthcare Provider Details

I. General information

NPI: 1417593310
Provider Name (Legal Business Name): JASON C HIPE RNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2019
Last Update Date: 11/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 E STATE ST
ROCKFORD IL
61104-2315
US

IV. Provider business mailing address

PO BOX 78866
MILWAUKEE WI
53278-8866
US

V. Phone/Fax

Practice location:
  • Phone: 779-696-4900
  • Fax:
Mailing address:
  • Phone: 779-696-7150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number041289299
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: