1063922417 NPI number — MRS. RYANNE E JACOBY SSP, NCSP, MA

Table of content: MRS. RYANNE E JACOBY SSP, NCSP, MA (NPI 1063922417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063922417 NPI number — MRS. RYANNE E JACOBY SSP, NCSP, MA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACOBY
Provider First Name:
RYANNE
Provider Middle Name:
E
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
SSP, NCSP, MA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NASON
Provider Other First Name:
RYANNE
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
SSP, NCSP, MA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063922417
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 S ADAMS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARTHAGE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62321-1420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-357-9202
Provider Business Mailing Address Fax Number:
217-357-3755

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 MILLER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARTHAGE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62321-1129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-357-2136
Provider Business Practice Location Address Fax Number:
217-357-3569
Provider Enumeration Date:
10/11/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TS0200X , with the licence number:  2351336 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1063922417 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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