Healthcare Provider Details

I. General information

NPI: 1780476499
Provider Name (Legal Business Name): JEFFREY THOMAS ADKISSON JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2025
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 FOXLEIGH CT
SAINT LOUIS MO
63131-1229
US

IV. Provider business mailing address

1555 FOXLEIGH CT
SAINT LOUIS MO
63131-1229
US

V. Phone/Fax

Practice location:
  • Phone: 314-917-1738
  • Fax:
Mailing address:
  • Phone: 314-917-1738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: