1417570920 NPI number — JESSICA WHELAN LLC

Table of content: (NPI 1417570920)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417570920 NPI number — JESSICA WHELAN LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JESSICA WHELAN LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
HOLON INCLUSIVE HEALTH SYSTEM
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417570920
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16549 CLAYTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILDWOOD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63011-1720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-236-5128
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUPO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62239-1325
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-470-1220
Provider Business Practice Location Address Fax Number:
833-914-0432
Provider Enumeration Date:
05/19/2020

Additional Information

Authorized Official

Authorized Official Last Name:
WHELAN
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
314-470-1220

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QI0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0855X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: STL70408459 . This is a "QUEST ACCOUNT" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 91674 . This is a "MCKESSON SUBMITTER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 691674 . This is a "MCKESSON SUBMITTER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1760018774 . This is a "NPI" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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