Healthcare Provider Details

I. General information

NPI: 1578785432
Provider Name (Legal Business Name): RICHARD L JACONETTE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 04/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

526 W STATE STREET
ROCKFORD IL
61101
US

IV. Provider business mailing address

1021 N MULFORD RD
ROCKFORD IL
61107-3877
US

V. Phone/Fax

Practice location:
  • Phone: 815-968-9300
  • Fax:
Mailing address:
  • Phone: 815-968-9300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036-102168
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: