Healthcare Provider Details

I. General information

NPI: 1922234764
Provider Name (Legal Business Name): SALLY JANE HENRICKSON RN/LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2009
Last Update Date: 06/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N TUCKER BLVD
SAINT LOUIS MO
63101-1114
US

IV. Provider business mailing address

800 N TUCKER BLVD
SAINT LOUIS MO
63101-1114
US

V. Phone/Fax

Practice location:
  • Phone: 314-802-1975
  • Fax: 314-802-1983
Mailing address:
  • Phone: 314-802-1975
  • Fax: 314-802-1983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number075944
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: