Provider Demographics
NPI:1851547129
Name:EASTER SEALS UCP
Entity Type:Organization
Organization Name:EASTER SEALS UCP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUDIOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:309-686-1177
Mailing Address - Street 1:507 E ARMSTRONG AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3201
Mailing Address - Country:US
Mailing Address - Phone:309-686-1177
Mailing Address - Fax:309-686-7722
Practice Address - Street 1:507 E ARMSTRONG AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3201
Practice Address - Country:US
Practice Address - Phone:309-686-1177
Practice Address - Fax:309-686-7722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147001286251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL144509Medicare PIN