Provider Demographics
NPI:1639069958
Name:BANDY, JENNIFER A
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:BANDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 HAMPTON RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-1374
Mailing Address - Country:US
Mailing Address - Phone:309-453-8119
Mailing Address - Fax:309-453-8119
Practice Address - Street 1:401 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:IL
Practice Address - Zip Code:61561-7585
Practice Address - Country:US
Practice Address - Phone:309-453-8119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-08
Last Update Date:2025-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209032685207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine