Healthcare Provider Details

I. General information

NPI: 1043971815
Provider Name (Legal Business Name): JORDAN WELLS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2022
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3437 CAROLINE ST
SAINT LOUIS MO
63104-1111
US

IV. Provider business mailing address

1107 MAYWOOD DR
EUREKA MO
63025-2765
US

V. Phone/Fax

Practice location:
  • Phone: 971-275-7979
  • Fax:
Mailing address:
  • Phone: 971-275-7979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2023010678
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: