Healthcare Provider Details

I. General information

NPI: 1043856701
Provider Name (Legal Business Name): MALLORY JEAN HENSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MALLORY JEAN STIMAC PA

II. Dates (important events)

Enumeration Date: 11/18/2019
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6800 STATE ROUTE 162 STE 200
MARYVILLE IL
62062-8521
US

IV. Provider business mailing address

12855 N 40 DR STE 375
SAINT LOUIS MO
63141-8657
US

V. Phone/Fax

Practice location:
  • Phone: 618-288-0900
  • Fax: 618-288-0909
Mailing address:
  • Phone: 314-567-6071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085007315
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: