Healthcare Provider Details

I. General information

NPI: 1538699244
Provider Name (Legal Business Name): JEFFREY TERRY VACEK DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 S 5TH ST
SAINT CHARLES MO
63301-2913
US

IV. Provider business mailing address

3924 SUMMER FOREST DR
SAINT CHARLES MO
63304-2642
US

V. Phone/Fax

Practice location:
  • Phone: 636-922-9182
  • Fax:
Mailing address:
  • Phone: 636-288-3458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2017019598
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: