Healthcare Provider Details

I. General information

NPI: 1740734730
Provider Name (Legal Business Name): JODI ALISE MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JODI ALISE URHAHN

II. Dates (important events)

Enumeration Date: 08/08/2016
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15740 S OUTER 40 RD
CHESTERFIELD MO
63017-2004
US

IV. Provider business mailing address

15740 S OUTER 40 RD
CHESTERFIELD MO
63017-2004
US

V. Phone/Fax

Practice location:
  • Phone: 636-735-4755
  • Fax: 636-237-4133
Mailing address:
  • Phone: 636-735-4755
  • Fax: 636-237-4133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2016033266
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: