Healthcare Provider Details

I. General information

NPI: 1558276402
Provider Name (Legal Business Name): JACKIE KAY HANNON DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 ROGERS ST
WATERLOO IL
62298-1780
US

IV. Provider business mailing address

312 QUENTIN CT
WATERLOO IL
62298-1150
US

V. Phone/Fax

Practice location:
  • Phone: 618-939-7761
  • Fax:
Mailing address:
  • Phone: 618-791-6735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number070.026314
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: