Healthcare Provider Details

I. General information

NPI: 1063956944
Provider Name (Legal Business Name): JENNIFER WILLIAMS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2016
Last Update Date: 04/01/2021
Certification Date: 04/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

452 SOVEREIGN CT STE A
BALLWIN MO
63011-4447
US

IV. Provider business mailing address

4858 ALLEMANIA ST
SAINT LOUIS MO
63116-1006
US

V. Phone/Fax

Practice location:
  • Phone: 636-222-8699
  • Fax: 636-238-5434
Mailing address:
  • Phone: 314-373-0766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2020032732
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number132226
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: