Basic Information
| Provider Information | |||||||||
| NPI: | 1740656438 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLEVENGER | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35 ALBANY RD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629037646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184575111 | ||||||||
| FaxNumber: | 6184576560 | ||||||||
| Practice Location | |||||||||
| Address1: | 35 ALBANY RD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629037646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184575111 | ||||||||
| FaxNumber: | 6184576560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2015 | ||||||||
| LastUpdateDate: | 09/01/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 041375950 | IL | N | Nursing Service Providers | Registered Nurse | 367500000X | 209013295 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.