Provider Demographics
NPI:1114259199
Name:JOUETT, JENNIFER JEANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JEANNE
Last Name:JOUETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1191 FORTUNE BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:SHILOH
Mailing Address - State:IL
Mailing Address - Zip Code:62269-7474
Mailing Address - Country:US
Mailing Address - Phone:618-622-7456
Mailing Address - Fax:618-627-0098
Practice Address - Street 1:1191 FORTUNE BLVD
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-7473
Practice Address - Country:US
Practice Address - Phone:618-622-7546
Practice Address - Fax:618-627-0098
Is Sole Proprietor?:No
Enumeration Date:2010-02-02
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003689363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085003689OtherILLINOIS LICENSE NUMBER