Healthcare Provider Details

I. General information

NPI: 1306087531
Provider Name (Legal Business Name): YASMIRA S EMOFOR LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: YASMIRA S JACKSON LPC

II. Dates (important events)

Enumeration Date: 03/18/2009
Last Update Date: 12/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5471 DR MARTIN LUTHER KING DR
SAINT LOUIS MO
63112-4265
US

IV. Provider business mailing address

5471 DR MARTIN LUTHER KING DR
SAINT LOUIS MO
63112-4265
US

V. Phone/Fax

Practice location:
  • Phone: 314-367-5820
  • Fax: 314-367-7010
Mailing address:
  • Phone: 314-367-5820
  • Fax: 314-367-7010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2011000673
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: