Provider Demographics
NPI:1366025660
Name:DYE, JACILYN C
Entity Type:Individual
Prefix:
First Name:JACILYN
Middle Name:C
Last Name:DYE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACILYN
Other - Middle Name:C
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 154
Mailing Address - Street 2:
Mailing Address - City:REDMON
Mailing Address - State:IL
Mailing Address - Zip Code:61949-0154
Mailing Address - Country:US
Mailing Address - Phone:217-552-8942
Mailing Address - Fax:
Practice Address - Street 1:201 LAFAYETTE AVE E
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4641
Practice Address - Country:US
Practice Address - Phone:217-235-5449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.004792224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant