Healthcare Provider Details

I. General information

NPI: 1972387504
Provider Name (Legal Business Name): JORDAN KELLY MANDEVILLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2023
Last Update Date: 08/23/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 S 5TH ST
SPRINGFIELD IL
62703-2312
US

IV. Provider business mailing address

61 BOURBAKI RD
NEW BERLIN IL
62670-4570
US

V. Phone/Fax

Practice location:
  • Phone: 217-544-3143
  • Fax:
Mailing address:
  • Phone: 217-801-8732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209028150
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: