Healthcare Provider Details

I. General information

NPI: 1548073448
Provider Name (Legal Business Name): JACLYN LEKAY NIX ALVAREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2025
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2941 CHAMPIONSHIP BLVD
SAINT LOUIS MO
63129-5274
US

IV. Provider business mailing address

2941 CHAMPIONSHIP BLVD
SAINT LOUIS MO
63129-5274
US

V. Phone/Fax

Practice location:
  • Phone: 918-282-6313
  • Fax:
Mailing address:
  • Phone: 314-282-5181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2017030931
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: