Provider Demographics
NPI:1053369546
Name:JACQUOT, BRIAN P (PA-C)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:P
Last Name:JACQUOT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 N EDWARD ST
Mailing Address - Street 2:GSBLL
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4163
Mailing Address - Country:US
Mailing Address - Phone:217-876-2857
Mailing Address - Fax:217-876-2874
Practice Address - Street 1:2300 N EDWARD ST
Practice Address - Street 2:SUITE 2350
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4163
Practice Address - Country:US
Practice Address - Phone:217-876-2880
Practice Address - Fax:217-876-2885
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10004104A363AS0400X
IL085001321363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
05732036OtherBLUE SHIELD GROUP NUMBER
487151OtherHEALTHLINK
P00265028Medicare PIN
IL0108OtherJOHN DEERE HEALTH PLAN
288584OtherPERSONAL CARE
ILK22297Medicare PIN
110350OtherHEALTH ALLIANCE
085001321000OtherOSF HEALTH PLANS
S96008Medicare UPIN