Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TS0200X | School Psychologist | 2351336 | IL |
NPI | 1063922417 |
---|---|
Provider Name | Mrs. Ryanne E Jacoby |
First Address | Carthage, IL 62321-1420 |
Second Address | Carthage, IL 62321-1129 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/10/2017 |
Last Update Date | 20/08/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1063922417 | (05) | IL |