Basic Information
| Provider Information | |||||||||
| NPI: | 1285306654 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEEB | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19248 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627949248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175287541 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1600 S 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | MORTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615502889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3092636154 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2021 | ||||||||
| LastUpdateDate: | 10/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0209023650 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.