Healthcare Provider Details

I. General information

NPI: 1740852730
Provider Name (Legal Business Name): JORDAN MALONE PMHNP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2021
Last Update Date: 07/11/2021
Certification Date: 07/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11477 OLDE CABIN RD STE 210
CREVE COEUR MO
63141-7129
US

IV. Provider business mailing address

11477 OLDE CABIN RD STE 210
CREVE COEUR MO
63141-7129
US

V. Phone/Fax

Practice location:
  • Phone: 314-997-5208
  • Fax: 314-997-5368
Mailing address:
  • Phone: 314-997-5208
  • Fax: 314-997-5368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JORDAN LEIGH MALONE
Title or Position: PSYCHIATRIC NURSE PRACTITIONER
Credential: APRN
Phone: 314-766-7290