Healthcare Provider Details

I. General information

NPI: 1255951398
Provider Name (Legal Business Name): JENNIFER DAYLE KING BROGAN CRADC, MARS, CH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2020
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3309 S KINGSHIGHWAY BLVD
SAINT LOUIS MO
63139-1101
US

IV. Provider business mailing address

197 CROSSWINDS DR
ARNOLD MO
63010-2018
US

V. Phone/Fax

Practice location:
  • Phone: 314-206-3708
  • Fax:
Mailing address:
  • Phone: 636-204-9766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number4111
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: