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General NPI Number Information
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NPI Number | 1316299456
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Entity Type | Individual
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Provider Name | JESSE LEE HENNEBERG APN
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Gender | Male
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Dates
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Enumeration Date | 10/14/2012
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Last Update Date | 07/19/2021
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Provider Practice Location Address
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Address Line | 530 NE GLEN OAK AVE
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City | PEORIA
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State | IL
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Zip | 61637-0001
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Country | US
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Telephone | 309-624-0629
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Fax |
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Provider Business Mailing Address
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Address Line | 201 E MADISON ST STE 328
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City | SPRINGFIELD
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State | IL
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Zip | 62702-5131
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Country | US
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Telephone | 217-545-7731
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LN0005X
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Taxonomy Name | Critical Care Neonatal Nurse Practitioner
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License Number | 209009916
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 363LN0000X
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Taxonomy Name | Neonatal Nurse Practitioner
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License Number | 209009916
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License Number State | IL
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