Healthcare Provider Details

I. General information

NPI: 1174163471
Provider Name (Legal Business Name): JESSICA SUE ASHBROOK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2020
Last Update Date: 01/14/2020
Certification Date: 01/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 N 9TH ST
FESTUS MO
63028-1364
US

IV. Provider business mailing address

PO BOX 1012
EAGLE BUTTE SD
57625-1012
US

V. Phone/Fax

Practice location:
  • Phone: 314-605-7524
  • Fax:
Mailing address:
  • Phone: 605-964-0706
  • Fax: 605-964-0545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number2017008764
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: