Basic Information
Provider Information | |||||||||
NPI: | 1306317383 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOHNSON | ||||||||
FirstName: | RACHAEL | ||||||||
MiddleName: | O | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PMHNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JEGEDE | ||||||||
OtherFirstName: | RACHAEL | ||||||||
OtherMiddleName: | O | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 109 CALIFORNIA ST | ||||||||
Address2: | PO BOX 577 | ||||||||
City: | CARTERVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 629180577 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6189858221 | ||||||||
FaxNumber: | 6189854635 | ||||||||
Practice Location | |||||||||
Address1: | 404 S. LEWIS LN | ||||||||
Address2: |   | ||||||||
City: | CARBONDALE | ||||||||
State: | IL | ||||||||
PostalCode: | 62901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6185199200 | ||||||||
FaxNumber: | 6185491288 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/17/2018 | ||||||||
LastUpdateDate: | 12/19/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 209018485 | IL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.