Healthcare Provider Details

I. General information

NPI: 1265566020
Provider Name (Legal Business Name): MRS. MARY JANE PATTERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12948 HIGHWAY 53
QULIN MO
63961-8260
US

IV. Provider business mailing address

12948 HIGHWAY 53
QULIN MO
63961-8260
US

V. Phone/Fax

Practice location:
  • Phone: 573-328-4026
  • Fax: 573-328-4883
Mailing address:
  • Phone: 573-328-4026
  • Fax: 573-328-4883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: