Provider Demographics
NPI:1285673780
Name:OTT, JAMIE J (FNP-C)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:J
Last Name:OTT
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:J
Other - Last Name:LOWRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2122 TROY RD STE 130
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-2540
Mailing Address - Country:US
Mailing Address - Phone:618-800-4500
Mailing Address - Fax:
Practice Address - Street 1:2122 TROY RD STE 130
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-2540
Practice Address - Country:US
Practice Address - Phone:618-800-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209003494363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL006015346OtherBLUE CROSS BLUE SHIELD OF
500012843OtherRAILROAD MEDICARE
500012843OtherRAILROAD MEDICARE
579310Medicare ID - Type Unspecified
ILF400145802Medicare PIN