Healthcare Provider Details

I. General information

NPI: 1811157399
Provider Name (Legal Business Name): JESSICA GLEASON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 11/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 N HIGHWAY 67
FLORISSANT MO
63031
US

IV. Provider business mailing address

13537 BARRETT PARKWAY DRIVE SUITE 105
BALLWIN MO
63021
US

V. Phone/Fax

Practice location:
  • Phone: 314-972-1442
  • Fax: 314-972-1533
Mailing address:
  • Phone: 314-821-9126
  • Fax: 314-821-9142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number112676
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: