Healthcare Provider Details

I. General information

NPI: 1144824574
Provider Name (Legal Business Name): JOHNNIE L JASPER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2020
Last Update Date: 11/25/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CENTRAL PUBLIC HEALTH CENTER (CPHC) 111 N. COUNTY FARM ROAD
WHEATON IL
60187
US

IV. Provider business mailing address

CENTRAL PUBLIC HEALTH CENTER (CPHC) 111 N. COUNTY FARM ROAD
WHEATON IL
60187
US

V. Phone/Fax

Practice location:
  • Phone: 630-627-1700
  • Fax:
Mailing address:
  • Phone: 630-627-1700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number22257
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: