Healthcare Provider Details

I. General information

NPI: 1003579335
Provider Name (Legal Business Name): MR. JAY BENOIT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2021
Last Update Date: 11/20/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 N RUTLEDGE ST FL 5
SPRINGFIELD IL
62702-6700
US

IV. Provider business mailing address

PO BOX 19639
SPRINGFIELD IL
62794-9639
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax:
Mailing address:
  • Phone: 217-545-8000
  • Fax: 844-470-2486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.024076
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: