Healthcare Provider Details

I. General information

NPI: 1295424760
Provider Name (Legal Business Name): JORDAN FEATHERSTON KENNAMANN MSN, CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2023
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S NEW BALLAS RD
SAINT LOUIS MO
63141-8221
US

IV. Provider business mailing address

5758 HUNTSPORT RD
SAINT LOUIS MO
63129-4355
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6299
  • Fax:
Mailing address:
  • Phone: 314-330-1198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2023009034
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: