Healthcare Provider Details

I. General information

NPI: 1225497639
Provider Name (Legal Business Name): JENNIFER LEANN TOON PORTER ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2016
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 S 6TH ST
SPRINGFIELD IL
62703-2499
US

IV. Provider business mailing address

PO BOX 19248
SPRINGFIELD IL
62794-9248
US

V. Phone/Fax

Practice location:
  • Phone: 175-287-5412
  • Fax:
Mailing address:
  • Phone: 217-528-7541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209013865
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: