Basic Information
Provider Information | |||||||||
NPI: | 1508438433 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HILL | ||||||||
FirstName: | JACOB | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4241 HIGHWAY 14 W | ||||||||
Address2: |   | ||||||||
City: | CHRISTOPHER | ||||||||
State: | IL | ||||||||
PostalCode: | 628221037 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6187242401 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1564 S WASHINGTON ST | ||||||||
Address2: |   | ||||||||
City: | DU QUOIN | ||||||||
State: | IL | ||||||||
PostalCode: | 628323849 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6185428702 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2021 | ||||||||
LastUpdateDate: | 07/12/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/12/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 043130445 | IL | Y |   | Nursing Service Providers | Licensed Practical Nurse |   |
No ID Information.