Provider Demographics
NPI:1679177935
Name:AINSWORTH, JERI
Entity Type:Individual
Prefix:
First Name:JERI
Middle Name:
Last Name:AINSWORTH
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 1:1773 E CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520-2317
Mailing Address - Country:US
Mailing Address - Phone:309-647-1321
Mailing Address - Fax:
Practice Address - Street 1:1773 E CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2317
Practice Address - Country:US
Practice Address - Phone:309-647-1321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-27
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051040850183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist