Provider Demographics
NPI:1902370703
Name:GREVE, JACKIE (NP)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:GREVE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E MILLER RD
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:IL
Mailing Address - Zip Code:61081-1252
Mailing Address - Country:US
Mailing Address - Phone:815-632-5285
Mailing Address - Fax:
Practice Address - Street 1:15 W 3RD ST
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081-3510
Practice Address - Country:US
Practice Address - Phone:815-625-0226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018227363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner