Healthcare Provider Details

I. General information

NPI: 1730861436
Provider Name (Legal Business Name): JAYLAHNI-TASHON MAILENA POPE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2023
Last Update Date: 08/02/2023
Certification Date: 08/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12380 DE PAUL DR
BRIDGETON MO
63044-2511
US

IV. Provider business mailing address

4042 SHAW BLVD
SAINT LOUIS MO
63110-3622
US

V. Phone/Fax

Practice location:
  • Phone: 314-447-9700
  • Fax:
Mailing address:
  • Phone: 314-296-7751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: