Healthcare Provider Details

I. General information

NPI: 1003300070
Provider Name (Legal Business Name): JESSICA MARIE BOGNER DOULA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2018
Last Update Date: 09/29/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 N RAILROAD ST
SPARLAND IL
61565-9807
US

IV. Provider business mailing address

304 N RAILROAD ST
SPARLAND IL
61565-9807
US

V. Phone/Fax

Practice location:
  • Phone: 309-238-5374
  • Fax:
Mailing address:
  • Phone: 309-238-5374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: