Healthcare Provider Details

I. General information

NPI: 1134494024
Provider Name (Legal Business Name): JENNIFER ANN HAYNES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2012
Last Update Date: 03/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9962 LIN FERRY DR SUITE 101
SAINT LOUIS MO
63123-6961
US

IV. Provider business mailing address

9962 LIN FERRY DR SUITE 101
SAINT LOUIS MO
63123-6961
US

V. Phone/Fax

Practice location:
  • Phone: 314-843-0043
  • Fax: 314-843-0201
Mailing address:
  • Phone: 314-843-0043
  • Fax: 314-843-0201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2012007108
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: