Healthcare Provider Details

I. General information

NPI: 1134577653
Provider Name (Legal Business Name): MISSOURI DEPARTMENT OF MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2016
Last Update Date: 08/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1706 E ELM ST
JEFFERSON CITY MO
65101-4130
US

IV. Provider business mailing address

1706 E ELM ST
JEFFERSON CITY MO
65101-4130
US

V. Phone/Fax

Practice location:
  • Phone: 573-751-2940
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LYNNE FULKS
Title or Position: DIRECTOR OF ADMINISTRATIVE SERVICES
Credential:
Phone: 573-751-8142