Healthcare Provider Details

I. General information

NPI: 1316247265
Provider Name (Legal Business Name): JENNIFER PATRICK, LCSW, LIMITED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2010
Last Update Date: 11/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2625 FAIRWAY DR STE. A
FULTON MO
65251-4023
US

IV. Provider business mailing address

2625 FAIRWAY DR STE. A
FULTON MO
65251-4023
US

V. Phone/Fax

Practice location:
  • Phone: 573-642-2102
  • Fax:
Mailing address:
  • Phone: 573-642-2102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1831182427
Identifier TypeOTHER
Identifier StateMO
Identifier IssuerNPI

VIII. Authorized Official

Name: MRS. JENNIFER MICHELE PATRICK
Title or Position: SOLE-PROPRIETOR
Credential: LCSW
Phone: 573-642-2102