Provider Demographics
NPI:1083397202
Name:RADFORD, JEWEL (RN)
Entity type:Individual
Prefix:MS
First Name:JEWEL
Middle Name:
Last Name:RADFORD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:337 AGNES DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-2202
Mailing Address - Country:US
Mailing Address - Phone:309-275-9051
Mailing Address - Fax:
Practice Address - Street 1:601 JAMES R THOMPSON BLVD STE 2015
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62201-1118
Practice Address - Country:US
Practice Address - Phone:618-482-6959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007017776163WE0003X
IL209.031195363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner