Healthcare Provider Details

I. General information

NPI: 1417371576
Provider Name (Legal Business Name): JENNIFER STARK FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER RASNIC

II. Dates (important events)

Enumeration Date: 02/10/2014
Last Update Date: 06/22/2025
Certification Date: 06/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12700 SOUTHFORK RD STE 153
SAINT LOUIS MO
63128-3201
US

IV. Provider business mailing address

1450 E 10TH ST
ROLLA MO
65401-3648
US

V. Phone/Fax

Practice location:
  • Phone: 314-543-5283
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number2012021855
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2025023492
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: