Provider Demographics
NPI:1730473018
Name:BAELE, JENNIFER RENEE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RENEE
Last Name:BAELE
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 1:5001 N BIG HOLLOW RD
Mailing Address - Street 2:T-0871
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-3538
Mailing Address - Country:US
Mailing Address - Phone:309-691-9310
Mailing Address - Fax:309-691-9310
Practice Address - Street 1:5001 N BIG HOLLOW RD
Practice Address - Street 2:T-0871
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-3538
Practice Address - Country:US
Practice Address - Phone:309-691-9310
Practice Address - Fax:309-691-9310
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-04
Last Update Date:2011-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.288059183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist