Healthcare Provider Details

I. General information

NPI: 1255450292
Provider Name (Legal Business Name): MARY JANE PARKS LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 W LAFAYETTE ST
WATSEKA IL
60970-1081
US

IV. Provider business mailing address

3044 E COUNTY HIGHWAY 31
DONOVAN IL
60931-6031
US

V. Phone/Fax

Practice location:
  • Phone: 815-432-1145
  • Fax:
Mailing address:
  • Phone: 815-429-3698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: