Healthcare Provider Details

I. General information

NPI: 1710121272
Provider Name (Legal Business Name): JENNY MYOUNG DETERT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2009
Last Update Date: 09/03/2021
Certification Date: 09/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10777 SUNSET OFFICE DR STE 110
SAINT LOUIS MO
63127-1019
US

IV. Provider business mailing address

415 PAR LN
KIRKWOOD MO
63122-2938
US

V. Phone/Fax

Practice location:
  • Phone: 314-781-7415
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2019015900
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: