Healthcare Provider Details

I. General information

NPI: 1275499634
Provider Name (Legal Business Name): JAMIE EWALD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2025
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3109 S GRAND BLVD STE 200G
SAINT LOUIS MO
63118-1039
US

IV. Provider business mailing address

6586 BRADLEY AVE
SAINT LOUIS MO
63139-2206
US

V. Phone/Fax

Practice location:
  • Phone: 314-656-6073
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2025032141
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: