Healthcare Provider Details

I. General information

NPI: 1689100083
Provider Name (Legal Business Name): JENNIFER SEDLACEK FNP-C, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2017
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PROFESSIONAL DR
ALTON IL
62002-5068
US

IV. Provider business mailing address

PO BOX 959203
SAINT LOUIS MO
63195-9203
US

V. Phone/Fax

Practice location:
  • Phone: 314-996-4545
  • Fax: 314-273-0140
Mailing address:
  • Phone: 314-996-4545
  • Fax: 314-273-0140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209016337
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209016337
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2017027608
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: