Individual
JORDAN KELLY MANDEVILLE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1020 S 5TH ST, SPRINGFIELD, IL 62703-2312
(217) 544-3143
Mailing address
61 BOURBAKI RD, NEW BERLIN, IL 62670-4570
(217) 801-8732
Taxonomy
Speciality
Code
Description
License number
State
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
209028150
IL
Other
Enumeration date
08/23/2023
Last updated
08/23/2023
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