Healthcare Provider Details

I. General information

NPI: 1750691689
Provider Name (Legal Business Name): JENNA NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2010
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12303 DEPAUL DR
SAINT LOUIS MO
63044
US

IV. Provider business mailing address

1426 CARRIAGE BRIDGE TRL
BALLWIN MO
63021-8426
US

V. Phone/Fax

Practice location:
  • Phone: 314-344-6000
  • Fax:
Mailing address:
  • Phone: 314-307-3407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2007027738
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number2007027738
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: