Provider Demographics
NPI:1497192785
Name:HANISCH, JESSE JOE (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:JOE
Last Name:HANISCH
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 HEALTH CARE DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62246-1159
Mailing Address - Country:US
Mailing Address - Phone:618-664-9831
Mailing Address - Fax:618-651-2842
Practice Address - Street 1:101 HEALTH CARE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:IL
Practice Address - Zip Code:62246-1159
Practice Address - Country:US
Practice Address - Phone:618-651-2732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-28
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036154307208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program