Provider Demographics
NPI:1932554714
Name:SCHUPBACH, JAMIE (NP)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:SCHUPBACH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:
Other - Last Name:GUZMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:900 MAIN ST
Mailing Address - Street 2:STE 600
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-1005
Mailing Address - Country:US
Mailing Address - Phone:309-671-8270
Mailing Address - Fax:309-672-3171
Practice Address - Street 1:900 MAIN ST
Practice Address - Street 2:STE 600
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1005
Practice Address - Country:US
Practice Address - Phone:309-671-8270
Practice Address - Fax:309-672-3171
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-28
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014135363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily