Provider Demographics
NPI:1528670171
Name:PAUL, JESSICA RENEE (OWNER)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:RENEE
Last Name:PAUL
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:DANIEL
Other - Middle Name:WILLIAM
Other - Last Name:PAUL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:647 W LOSEY ST STE 3
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-2594
Mailing Address - Country:US
Mailing Address - Phone:309-351-7885
Mailing Address - Fax:309-973-4121
Practice Address - Street 1:647 W LOSEY ST STE 3
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-2594
Practice Address - Country:US
Practice Address - Phone:309-351-7885
Practice Address - Fax:309-973-4121
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL85-2406035OtherIN HOME CARE SERVICES