Healthcare Provider Details

I. General information

NPI: 1265827729
Provider Name (Legal Business Name): JESSICA E LUCCA AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA E SWINFORD AGACNP-BC

II. Dates (important events)

Enumeration Date: 04/01/2015
Last Update Date: 12/23/2019
Certification Date: 12/23/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 E MADISON ST STE 1F
SPRINGFIELD IL
62701-3118
US

IV. Provider business mailing address

PO BOX 3428
SPRINGFIELD IL
62708-3428
US

V. Phone/Fax

Practice location:
  • Phone: 217-788-3948
  • Fax: 217-527-3209
Mailing address:
  • Phone: 217-788-3948
  • Fax: 217-527-3209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number209.012661
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209012661
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209.012661
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number209.012661
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: