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Organization
FT. JESSE IMAGING CENTER LLC
Active
Organization
FT. JESSE IMAGING CENTER LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
AMY STOUT (PRESIDENT/CEO)
(615) 261-2306
Entity
Organization
Contact information
Practice address
2200 FORT JESSE RD, SUITE 130, NORMAL, IL 61761-6286
(309) 454-5552
(309) 454-5452
Mailing address
2200 FORT JESSE RD, SUITE 130, NORMAL, IL 61761-6286
(309) 454-5552
(309) 454-5452
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
—
—
261QR0200X
Radiology Clinic/Center
Primary
9256804
IL
261QR0206X
Mammography Clinic/Center
9256804
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
46015604001
—
IL
Enumeration date
05/27/2006
Last updated
12/16/2025
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