Healthcare Provider Details

I. General information

NPI: 1790100089
Provider Name (Legal Business Name): JENNIFER SOUTHWARD CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER OLDHAM

II. Dates (important events)

Enumeration Date: 02/24/2014
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 SMIZER MILL RD
FENTON MO
63026-3483
US

IV. Provider business mailing address

12680 OLIVE BLVD
SAINT LOUIS MO
63141-6289
US

V. Phone/Fax

Practice location:
  • Phone: 636-717-1350
  • Fax: 636-717-1355
Mailing address:
  • Phone: 314-529-5660
  • Fax: 636-717-1355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2013037116
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: