Healthcare Provider Details

I. General information

NPI: 1558201848
Provider Name (Legal Business Name): JASMINE ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15740 S OUTER 40 RD
CHESTERFIELD MO
63017-2004
US

IV. Provider business mailing address

112 UNIVERSAL DR
SAINT PETERS MO
63376-4418
US

V. Phone/Fax

Practice location:
  • Phone: 636-237-4775
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2015004570
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: