Healthcare Provider Details

I. General information

NPI: 1083575989
Provider Name (Legal Business Name): JESSICA DOMKE LPC, ATR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2025
Last Update Date: 11/20/2025
Certification Date: 11/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12143 OLD SAINT CHARLES RD
BRIDGETON MO
63044-2816
US

IV. Provider business mailing address

12143 OLD SAINT CHARLES RD
BRIDGETON MO
63044-2816
US

V. Phone/Fax

Practice location:
  • Phone: 314-656-6113
  • Fax:
Mailing address:
  • Phone: 314-656-6113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2022037793
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: