Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 038011188 | IL |
NPI | 1003076464 |
---|---|
Provider Name | Jamie Devon Stephens |
First Address | Breese, IL 62230-1528 |
Second Address | Breese, IL 62230-1528 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/06/2008 |
Last Update Date | 10/06/2008 |