Healthcare Provider Details

I. General information

NPI: 1851889281
Provider Name (Legal Business Name): JENNIFER M DERNER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2018
Last Update Date: 07/20/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 OAK TREE DR
SAINT LOUIS MO
63119-4760
US

IV. Provider business mailing address

9051 WATSON RD #134
CRESTWOOD MO
63126-2220
US

V. Phone/Fax

Practice location:
  • Phone: 314-328-5701
  • Fax: 314-408-8400
Mailing address:
  • Phone: 314-328-5701
  • Fax: 314-408-8400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number005064
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: