Provider Demographics
NPI:1942536883
Name:COFFMAN, JACQUELINE ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN
Last Name:COFFMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 LAKE LAND BLVD
Mailing Address - Street 2:SUITE 202, SYSTEM PRACTICES
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-5283
Mailing Address - Country:US
Mailing Address - Phone:217-258-3370
Mailing Address - Fax:217-258-3379
Practice Address - Street 1:2200 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:IL
Practice Address - Zip Code:61944-2966
Practice Address - Country:US
Practice Address - Phone:217-463-4340
Practice Address - Fax:217-463-4342
Is Sole Proprietor?:No
Enumeration Date:2009-10-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003642363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208905103Medicare PIN