Provider Demographics
NPI:1508401936
Name:PENCE, JAMIE
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:PENCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:699 WESCLIN RD
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62293-2627
Mailing Address - Country:US
Mailing Address - Phone:618-224-7341
Mailing Address - Fax:
Practice Address - Street 1:699 WESCLIN RD
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:IL
Practice Address - Zip Code:62293-2627
Practice Address - Country:US
Practice Address - Phone:618-224-7341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-08
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool