Provider Demographics
NPI:1417962226
Name:WISEHART, JEROME ALLEN
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:ALLEN
Last Name:WISEHART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14940 EAST ST
Mailing Address - Street 2:
Mailing Address - City:WHITTINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:62897-1335
Mailing Address - Country:US
Mailing Address - Phone:618-629-2585
Mailing Address - Fax:
Practice Address - Street 1:1265 S MILL ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:IL
Practice Address - Zip Code:62263-2004
Practice Address - Country:US
Practice Address - Phone:618-327-4833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2803237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL270033874009Medicaid
IL270033874011Medicaid