Provider Demographics
NPI:1003076464
Name:STEPHENS, JAMIE DEVON (DC)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:DEVON
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4211
Mailing Address - Country:US
Mailing Address - Phone:217-234-2800
Mailing Address - Fax:
Practice Address - Street 1:801 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4211
Practice Address - Country:US
Practice Address - Phone:217-234-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011188111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038011188OtherCHIROPRACTOR LICENSE