Healthcare Provider Details

I. General information

NPI: 1619223591
Provider Name (Legal Business Name): NICOLE ASHLEY JAZO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2012
Last Update Date: 08/05/2022
Certification Date: 08/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 FOXPOINTE DR
SYCAMORE IL
60178-3221
US

IV. Provider business mailing address

PO BOX 1109
DEKALB IL
60115-7109
US

V. Phone/Fax

Practice location:
  • Phone: 815-748-8334
  • Fax: 815-748-8921
Mailing address:
  • Phone: 815-766-3024
  • Fax: 815-756-2944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149020096
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: