Provider Demographics
NPI:1407847569
Name:JAHN, DAVID M (PAC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:JAHN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IL
Mailing Address - Zip Code:61856-1151
Mailing Address - Country:US
Mailing Address - Phone:217-762-2115
Mailing Address - Fax:217-762-6165
Practice Address - Street 1:1111 N STATE ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IL
Practice Address - Zip Code:61856-1151
Practice Address - Country:US
Practice Address - Phone:217-762-2115
Practice Address - Fax:217-762-6165
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL94548Medicare ID - Type UnspecifiedWPS MEDICARE
ILS77645Medicare UPIN