Provider Demographics
NPI:1659123602
Name:SCROGGINS, JEWEL
Entity Type:Individual
Prefix:
First Name:JEWEL
Middle Name:
Last Name:SCROGGINS
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 1:805 SAINT THOMAS LN
Mailing Address - Street 2:
Mailing Address - City:CAHOKIA
Mailing Address - State:IL
Mailing Address - Zip Code:62206-1810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:805 SAINT THOMAS LN
Practice Address - Street 2:
Practice Address - City:CAHOKIA
Practice Address - State:IL
Practice Address - Zip Code:62206-1810
Practice Address - Country:US
Practice Address - Phone:618-578-3052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017041810164W00000X
IL043112591164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse