Healthcare Provider Details

I. General information

NPI: 1124963103
Provider Name (Legal Business Name): LAUREN JAKUBISIN
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2026
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PARKVIEW PL
SAINT LOUIS MO
63110-1038
US

IV. Provider business mailing address

4466 W PINE BLVD APT 6B
SAINT LOUIS MO
63108-2330
US

V. Phone/Fax

Practice location:
  • Phone: 314-747-3000
  • Fax:
Mailing address:
  • Phone: 704-277-2774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number0001331621
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: