Basic Information
| Provider Information | |||||||||
| NPI: | 1609354315 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAYLOR | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LORRAINE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | APRN ,DNP, CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 544 W PERSHING RD | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625263226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178722400 | ||||||||
| FaxNumber: | 2178754680 | ||||||||
| Practice Location | |||||||||
| Address1: | 544 W PERSHING RD | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625263226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178722400 | ||||||||
| FaxNumber: | 2178754680 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2018 | ||||||||
| LastUpdateDate: | 07/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 07/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 209024795 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 367A00000X | APRN9492930 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 100819800 | 05 | FL | MEDICAID |