Provider Demographics
NPI:1164646089
Name:STEVENS, JANDA TERESE (MD)
Entity Type:Individual
Prefix:DR
First Name:JANDA
Middle Name:TERESE
Last Name:STEVENS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 E CARPENTER ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62769-1000
Mailing Address - Country:US
Mailing Address - Phone:217-544-6464
Mailing Address - Fax:
Practice Address - Street 1:800 E. CARPENTER
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62769
Practice Address - Country:US
Practice Address - Phone:217-544-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2021-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301083809207P00000X
WAMD60073279207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8551186Medicaid
MIP00470689OtherRAILROAD MEDICARE
IL036126564 1Medicaid
IL036126564 1Medicaid
WA8883423Medicare PIN
IL207236015Medicare PIN