Provider Demographics
NPI:1922682822
Name:JACKSONVILLE IL WELLNESS
Entity Type:Organization
Organization Name:JACKSONVILLE IL WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:S
Authorized Official - Last Name:O'NEIL
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:217-204-8081
Mailing Address - Street 1:1329 W COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-2216
Mailing Address - Country:US
Mailing Address - Phone:217-204-8081
Mailing Address - Fax:
Practice Address - Street 1:1521 W WALNUT ST STE D
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-1153
Practice Address - Country:US
Practice Address - Phone:217-279-5815
Practice Address - Fax:217-279-5816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-07
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty