Individual
MR. JESSE LEE HENNEBERG
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
APN
Contact information
Practice address
530 NE GLEN OAK AVE, PEORIA, IL 61637-0001
(309) 624-0629
Mailing address
201 E MADISON ST STE 328, SPRINGFIELD, IL 62702-5131
(217) 545-7731
Taxonomy
Speciality
Code
Description
License number
State
363LN0000X
Neonatal Nurse Practitioner
Primary
209009916
IL
363LN0005X
Critical Care Neonatal Nurse Practitioner
209009916
IL
Other
Enumeration date
10/14/2012
Last updated
07/19/2021
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