Healthcare Provider Details

I. General information

NPI: 1790218048
Provider Name (Legal Business Name): JILL BUERY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2017
Last Update Date: 04/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S WOODLAWN AVE STE 15
O'FALLON MO
63366
US

IV. Provider business mailing address

612 SUN LAKE DR
SAINT CHARLES MO
63301-3027
US

V. Phone/Fax

Practice location:
  • Phone: 636-379-1779
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number2015045062
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: