Provider Demographics
NPI:1801643812
Name:CLAY, JASMINE ALINE (APRN)
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:ALINE
Last Name:CLAY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1170 FORTUNE BLVD
Mailing Address - Street 2:
Mailing Address - City:SHILOH
Mailing Address - State:IL
Mailing Address - Zip Code:62269-7358
Mailing Address - Country:US
Mailing Address - Phone:618-997-5266
Mailing Address - Fax:833-431-2272
Practice Address - Street 1:1170 FORTUNE BLVD
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-7358
Practice Address - Country:US
Practice Address - Phone:618-997-5266
Practice Address - Fax:833-431-2272
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-06
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209029670363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty