Healthcare Provider Details

I. General information

NPI: 1821019969
Provider Name (Legal Business Name): JACQUELINE R CLAYTON APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 01/15/2020
Certification Date: 01/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 W MAIN ST
SHELBYVILLE IL
62565-1252
US

IV. Provider business mailing address

1005 HEALTH CENTER DR STE 201
MATTOON IL
61938-4693
US

V. Phone/Fax

Practice location:
  • Phone: 217-774-4305
  • Fax: 217-774-4306
Mailing address:
  • Phone: 217-238-6055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number277000144
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209-006100
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: