Provider Demographics
NPI:1699043562
Name:STICH, JEANNE ANN (BSN, RN)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:ANN
Last Name:STICH
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:MT. VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-0054
Mailing Address - Country:US
Mailing Address - Phone:618-242-1510
Mailing Address - Fax:618-242-0958
Practice Address - Street 1:16342 N IL HWY 37
Practice Address - Street 2:
Practice Address - City:MT. VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-0054
Practice Address - Country:US
Practice Address - Phone:618-242-1510
Practice Address - Fax:618-242-0958
Is Sole Proprietor?:No
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.326461163W00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No171M00000XOther Service ProvidersCase Manager/Care Coordinator