MEDICARE: JONATHAN EDWARDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	209012330	IL

General Provider Information

NPI Number	:	1164820312
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN EDWARDS

Provider Business Mailing Address
First Line	:	1405 E 12TH ST
Second Line	:	SUITE 600
City	:	MENDOTA
State	:	IL
Zip	:	61342-9010
Country	:	US
Telephone Number	:	815-538-7200
Fax Number	:	815-539-1444

Provider Business Practice Location Address
First Line	:	1405 E 12TH ST
Second Line	:	SUITE 600
City	:	MENDOTA
State	:	IL
Zip	:	61342-9010
Country	:	US
Telephone Number	:	815-538-7200
Fax Number	:	815-539-1444

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/19/2014
Last Update Date	:	12/19/2014

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Directions to “ JONATHAN EDWARDS ” Practice Location

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