MR. JESSE LEE HENNEBERG (NPI# 1316299456) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1316299456 |
| Entity Type | Individual |
| Full Name | MR. JESSE LEE HENNEBERG |
| Credential | APN |
| Practice Address |
530 Ne Glen Oak Ave Peoria IL 61637-0001 |
| Practice Telephone | 3096240629 |
| Enumeration Date | 2012-10-14 |
| Last Update Date | 2012-10-14 |
| Gender Code | M |
| Is Sole Proprietor | Y |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| N | 363LN0000X |
Nurse Practitioner Specialization: Neonatal |
209009916 | IL | Physician Assistants & Advanced Practice Nursing Providers |
| Y | 363LN0005X |
Nurse Practitioner Specialization: Neonatal, Critical Care |
209009916 | IL | Physician Assistants & Advanced Practice Nursing Providers |
| Street Address |
530 NE GLEN OAK AVE |
| City | PEORIA |
| State | IL |
| Zip Code | 61637-0001 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1346235777 | Jack Michael Gibson | Obstetrics & Gynecology | 530 Ne Glen Oak Ave, Peoria, IL 61637-0001 | 2005-09-12 |
| 1053912188 | Janie Clary | Nurse Practitioner | 530 Ne Glen Oak Ave, Peoria, IL 61637-0001 | 2020-11-04 |
| 1265030548 | Christina David | Nurse Practitioner | 530 Ne Glen Oak Ave, Peoria, IL 61637-0001 | 2020-10-09 |
| 1033726831 | Corry Lynn Rediger | Occupational Therapist | 530 Ne Glen Oak Ave, Peoria, IL 61637-0001 | 2020-09-25 |
| 1720694094 | Katelynn M Madden | Clinical Nurse Specialist | 530 Ne Glen Oak Ave, Peoria, IL 61637-0001 | 2020-09-21 |
| 1568074474 | Amanda Diane Beoletto | Pharmacist | 530 Ne Glen Oak Ave, Peoria, IL 61637-0001 | 2020-08-21 |
| 1881212892 | Mohammad Mousbah Al-tabbaa | Student in an Organized Health Care Education/Training Program | 530 Ne Glen Oak Ave, Peoria, IL 61637-0001 | 2020-07-07 |
| 1750909693 | Mohammad Gareeb | Student in an Organized Health Care Education/Training Program | 530 Ne Glen Oak Ave, Peoria, IL 61637-0001 | 2020-07-07 |
| 1376160846 | Bassel Elia Abouzeid | Student in an Organized Health Care Education/Training Program | 530 Ne Glen Oak Ave, Peoria, IL 61637 | 2020-07-01 |
| 1700403516 | Christina Marie Spurgeon | Nurse Practitioner | 530 Ne Glen Oak Ave, Peoria, IL 61637-0001 | 2020-06-26 |
| Find all providers in the same location | ||||
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1780200865 | Kuang Chuen Liu | Pediatrics | 530 Ne Glen Oak Ave, Peoria, Peoria, IL 61637 | 2020-06-24 |
| 1174184527 | Manisha Tharoor | Student in an Organized Health Care Education/Training Program | 530 N.e Glen Oak Ave, Peoria, IL 61637 | 2019-06-26 |
| 1609436724 | Sriviji Senthil Kumaran | Student in an Organized Health Care Education/Training Program | 530. N.e Glen Oak Ave., Peoria, IL 61637 | 2019-06-20 |
| 1780240929 | Abuzar Ali Asif | Student in an Organized Health Care Education/Training Program | 530 N. E. Glen Oak Ave., Peoria, IL 61637 | 2019-05-14 |
| 1518328665 | Jenna Bishop | Dietitian, Registered | 600 Ne Water Street, Peoria, IL 61637 | 2016-03-17 |
| 1194133850 | Ashish Kumar Roy | Internal Medicine | 530 N.e. Glen Oak Ave, Peoria, IL 61637 | 2014-07-25 |
| 1265720510 | Reuben Antony | Pediatrics | 530 Ne Glen Oak Ave., C/o Ms Suzy Lewellen, Peoria, IL 61637 | 2011-07-20 |
| 1366673436 | Joseph William Hauter | Emergency Medicine | 830 Ne Glen Oak Ave, Peoria, IL 61637 | 2009-08-06 |
| 1437380748 | Jeremy R Monroe | Emergency Medicine | 530 Glen Oak, Osf St Francis Medical Center, Peoria, IL 61637 | 2009-08-04 |
| 1326244682 | Maria S. Parr | Psychiatry & Neurology | Osf Saint Francis Medical Center, 530 N.e.glen Oak Ave., Peoria, FL 61637 | 2007-06-25 |
| Find all providers in zip 61637 | ||||
| Taxonomy Code | 363LN0005X |
| Grouping | Physician Assistants & Advanced Practice Nursing Providers |
| Classification | Nurse Practitioner |
| Specialization | Neonatal, Critical Care |
| Definition to come... |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1700403516 | Christina Marie Spurgeon | Nurse Practitioner | 530 Ne Glen Oak Ave, Peoria, IL 61637-0001 | 2020-06-26 |
| 1366979437 | Michelle Dawn Cunningham | Nurse Practitioner | 530 Ne Glen Oak Ave, Peoria, IL 61637-0001 | 2017-05-18 |
| 1982136271 | Saint Francis Medical Center | Nurse Practitioner | 530 Ne Glen Oak Ave, Peoria, IL 61637-0001 | 2017-03-28 |
| 1275958373 | Brittany Welch | Nurse Practitioner | 530 Ne Glen Oak Ave, Peoria, IL 61637-0001 | 2014-02-26 |
| 1609145853 | Emily Liles Huamani | Nurse Practitioner | 530 Ne Glen Oak Ave, Peoria, IL 61637-0001 | 2011-12-16 |
| 1215265327 | Mildred Elaine Shafer | Nurse Practitioner | 530 Ne Glen Oak Ave, Peoria, IL 61637-0002 | 2009-12-01 |
| 1023346582 | Laura K Bowers | Nurse Practitioner | 530 Ne Glen Oak Ave, Peoria, IL 61637-0001 | 2009-11-20 |
| 1053649574 | Kathleen Jo Moersch | Nurse Practitioner | 530 Ne Glen Oak Ave, Peoria, IL 61637-0001 | 2009-11-20 |
| 1679801187 | Jan Marie Galbreath | Nurse Practitioner | 530 Ne Glen Oak Ave, Peoria, IL 61637-0001 | 2009-11-20 |
| 1699002709 | Denise Mary Cornell | Nurse Practitioner | 530 Ne Glen Oak Ave, Peoria, IL 61637-0001 | 2009-11-10 |
| Find all providers in PEORIA | ||||
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.