# JEFFERSON STREET CLINIC, SC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1366637258
- **Authorized official:** DR. LARRY STEPHEN PATTON D.O. (PRESIDENT)
- **Authorized official phone:** (309) 266-9711

## Contact information

- **Practice address:** 107 E JEFFERSON STREET, MORTON, IL 61550-0180
- **Practice address phone:** (309) 266-9711
- **Practice address fax:** (309) 266-6322
- **Mailing address:** 107 E JEFFERSON ST, PO BOX 180, MORTON, IL 61550-2001
- **Mailing address phone:** (309) 266-9711
- **Mailing address fax:** (309) 266-6322

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261Q00000X | Clinic/Center | — | IL | Yes |

## Other

- **Enumeration date:** 09/13/2007
- **Last updated:** 09/13/2007

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 9015653 | BLUE CROSS BLUE SHIELD | IL |