Provider Demographics
NPI: | 1033544747 |
---|---|
Name: | WHELAN, JESSICA (PMHNP-BC) |
Entity Type: | Individual |
Prefix: | |
First Name: | JESSICA |
Middle Name: | |
Last Name: | WHELAN |
Suffix: | |
Gender: | F |
Credentials: | PMHNP-BC |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 16549 CLAYTON RD STE 10 |
Mailing Address - Street 2: | |
Mailing Address - City: | WILDWOOD |
Mailing Address - State: | MO |
Mailing Address - Zip Code: | 63011-1720 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 314-470-1220 |
Mailing Address - Fax: | 833-914-0432 |
Practice Address - Street 1: | 702 W CHESTNUT ST |
Practice Address - Street 2: | |
Practice Address - City: | BLOOMINGTON |
Practice Address - State: | IL |
Practice Address - Zip Code: | 61701-2814 |
Practice Address - Country: | US |
Practice Address - Phone: | 309-557-1400 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2013-09-12 |
Last Update Date: | 2022-09-14 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IL | 277000634 | 103TP2701X, 163WA0400X, 163WC1600X, 163WG0000X, 163WN0800X, 1744R1102X, 2084P0301X, 364SC2300X, 364SH1100X, 364SP0810X, 364SP0811X, 364SP0812X, 364SP0813X, 363LP0808X |
MO | 2013029034 | 363LP0808X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LP0808X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psychiatric/Mental Health |
No | 103TP2701X | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy |
No | 163WA0400X | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) |
No | 163WC1600X | Nursing Service Providers | Registered Nurse | Continuing Education/Staff Development |
No | 163WG0000X | Nursing Service Providers | Registered Nurse | General Practice |
No | 163WN0800X | Nursing Service Providers | Registered Nurse | Neuroscience |
No | 1744R1102X | Other Service Providers | Specialist | Research Study |
No | 2084P0301X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Brain Injury Medicine |
No | 364SC2300X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Chronic Care |
No | 364SH1100X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Holistic |
No | 364SP0810X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psychiatric/Mental Health, Child & Family |
No | 364SP0811X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psychiatric/Mental Health, Chronically Ill |
No | 364SP0812X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psychiatric/Mental Health, Community |
No | 364SP0813X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psychiatric/Mental Health, Geropsychiatric |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IL | 277000634 | Other | STATE LICENSE IL |
IL | 6555912834012 | Other | SURESCRIPTS |
IL | 377000614 | Other | IL PRESCRIBING LICENSE |