1205100187 NPI number — JESSICA ELIZABETH WILLMANN PLPC

Table of content: JESSICA ELIZABETH WILLMANN PLPC (NPI 1205100187)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205100187 NPI number — JESSICA ELIZABETH WILLMANN PLPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLMANN
Provider First Name:
JESSICA
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PLPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HANZLICK
Provider Other First Name:
JESSICA
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1205100187
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1004 POWELL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLLINSVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62234-3136
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-980-2332
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14615 MANCHESTER RD
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
BALLWIN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63011-3790
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-488-2019
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/24/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  2011031450 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com