Healthcare Provider Details

I. General information

NPI: 1235103003
Provider Name (Legal Business Name): JESSE D HELTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2006
Last Update Date: 08/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 OSAGE EXECUTIVE CIR
HOUSE SPRINGS MO
63051-1382
US

IV. Provider business mailing address

100 OSAGE EXECUTIVE CIR
HOUSE SPRINGS MO
63051-1382
US

V. Phone/Fax

Practice location:
  • Phone: 636-677-9977
  • Fax: 636-677-9179
Mailing address:
  • Phone: 636-677-9977
  • Fax: 636-677-9179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2006025334
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR6F69
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberDO113093
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateMO

VIII. Authorized Official

Name: JESSE DWAYNE HELTON
Title or Position: OWNER
Credential: DO
Phone: 636-677-9977