Provider Demographics
NPI:1770239675
Name:BACHTOLD, JARA
Entity Type:Individual
Prefix:
First Name:JARA
Middle Name:
Last Name:BACHTOLD
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 1:303 LANDMARK DR STE 2B
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-6164
Mailing Address - Country:US
Mailing Address - Phone:309-808-2388
Mailing Address - Fax:
Practice Address - Street 1:303 LANDMARK DR STE 2B
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6164
Practice Address - Country:US
Practice Address - Phone:309-808-2388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-01
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.130912164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse