Healthcare Provider Details

I. General information

NPI: 1285145748
Provider Name (Legal Business Name): JERMAINE ANDRE WATSON LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2017
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W PORT PLZ
SAINT LOUIS MO
63146-3011
US

IV. Provider business mailing address

546 CHAPEL CROSS DR
FLORISSANT MO
63031-1674
US

V. Phone/Fax

Practice location:
  • Phone: 314-749-0760
  • Fax: 636-333-0029
Mailing address:
  • Phone: 314-749-0760
  • Fax: 636-333-0029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2017034860
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: