Provider Demographics
NPI:1699528174
Name:ACFALLE, JASMINE PRAMOJ
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:PRAMOJ
Last Name:ACFALLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 MAIN ST STE C
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-1080
Mailing Address - Country:US
Mailing Address - Phone:309-672-4986
Mailing Address - Fax:
Practice Address - Street 1:815 MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1080
Practice Address - Country:US
Practice Address - Phone:309-672-4986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-08
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.084698207Q00000X
0000000000000390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program