Healthcare Provider Details

I. General information

NPI: 1477220598
Provider Name (Legal Business Name): JACQUELINE SUE PUDLOWSKI LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2021
Last Update Date: 08/26/2021
Certification Date: 08/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

789 THUNDER HILL DR
O FALLON MO
63368-4094
US

IV. Provider business mailing address

789 THUNDER HILL DR
O FALLON MO
63368-4094
US

V. Phone/Fax

Practice location:
  • Phone: 314-409-0021
  • Fax:
Mailing address:
  • Phone: 314-409-0021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2004006777
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: