Provider Demographics
NPI:1730525320
Name:REED, JENNIFER ROSE CARROLL (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROSE CARROLL
Last Name:REED
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 198
Mailing Address - Street 2:
Mailing Address - City:OQUAWKA
Mailing Address - State:IL
Mailing Address - Zip Code:61469-0198
Mailing Address - Country:US
Mailing Address - Phone:309-867-2202
Mailing Address - Fax:
Practice Address - Street 1:101 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:STRONGHURST
Practice Address - State:IL
Practice Address - Zip Code:61480-5033
Practice Address - Country:US
Practice Address - Phone:309-924-2424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-22
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036140446207R00000X
IN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036140446Medicaid