Healthcare Provider Details

I. General information

NPI: 1861121253
Provider Name (Legal Business Name): JENA LYN SCHOLL ACNPC-AG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2022
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 LACEY ST
CAPE GIRARDEAU MO
63701-5230
US

IV. Provider business mailing address

1349 N MOUNT AUBURN RD
CAPE GIRARDEAU MO
63701-1727
US

V. Phone/Fax

Practice location:
  • Phone: 573-334-4822
  • Fax:
Mailing address:
  • Phone: 573-334-9564
  • Fax: 573-334-1879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number2022020575
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2022020575
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number2022020575
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: