Provider Demographics
NPI:1093241960
Name:JAMIESON COMMUNITY CENTER
Entity Type:Organization
Organization Name:JAMIESON COMMUNITY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOWEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-734-4251
Mailing Address - Street 1:1025 S 2ND ST
Mailing Address - Street 2:PO BOX 495
Mailing Address - City:MONMOUTH
Mailing Address - State:IL
Mailing Address - Zip Code:61462-2715
Mailing Address - Country:US
Mailing Address - Phone:309-734-4251
Mailing Address - Fax:
Practice Address - Street 1:1025 S 2ND ST
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:IL
Practice Address - Zip Code:61462-2715
Practice Address - Country:US
Practice Address - Phone:309-734-4251
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL187-26-2017251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL20150720755779OtherIMPACT - ILLINOIS PROVIDER ENROLLMENT SYSTEM