MEDICARE: HOLLY ALEGRO JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	343900000X	Non-emergency Medical Transport (VAN)		MO

General Provider Information

NPI Number	:	1689156721
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOLLY ALEGRO JACKSON

Provider Business Mailing Address
First Line	:	10550 MURAT DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-4524
Country	:	US
Telephone Number	:	314-358-6051
Fax Number	:	314-869-3373

Provider Business Practice Location Address
First Line	:	10550 MURAT DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-4524
Country	:	US
Telephone Number	:	314-358-6051
Fax Number	:	314-869-3373

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2018
Last Update Date	:	09/05/2018

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