Provider Demographics
NPI:1811248651
Name:PEMBLE, JENNIFER S (NNP-BC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:PEMBLE
Suffix:
Gender:F
Credentials:NNP-BC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:S
Other - Last Name:GIBBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NNP-BC
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2529
Practice Address - Country:US
Practice Address - Phone:217-383-3266
Practice Address - Fax:217-383-3463
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020010760363LN0000X
IL209009760363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid