Provider Demographics
NPI:1699190355
Name:POOLE, JANE M
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:M
Last Name:POOLE
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 1:107 E CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:IL
Mailing Address - Zip Code:62048-1103
Mailing Address - Country:US
Mailing Address - Phone:618-830-9290
Mailing Address - Fax:
Practice Address - Street 1:107 E CHERRY ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:IL
Practice Address - Zip Code:62048-1103
Practice Address - Country:US
Practice Address - Phone:618-830-9290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-04
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL46-4715140172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver