Individual
CHRISTA DAWN JENNETTE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
1113 KEIFFER DR, OLNEY, IL 62450
(618) 392-4106
Mailing address
1113 KEIFFER DR, OLNEY, IL 62450
(618) 392-4106
Taxonomy
Speciality
Code
Description
License number
State
347C00000X
Private Vehicle
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
189837230
—
IL
Enumeration date
04/30/2008
Last updated
04/30/2008
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