Healthcare Provider Details

I. General information

NPI: 1366269466
Provider Name (Legal Business Name): MICHAEL JASPER IGHO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2024
Last Update Date: 01/10/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N 1ST ST
SPRINGFIELD IL
62781-0001
US

IV. Provider business mailing address

1715 SPARTAN DR
CHATHAM IL
62629-8137
US

V. Phone/Fax

Practice location:
  • Phone: 217-788-3000
  • Fax:
Mailing address:
  • Phone: 217-361-9442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number291077
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209031001
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041489427
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: