Healthcare Provider Details

I. General information

NPI: 1679123707
Provider Name (Legal Business Name): MR. KEITH L JONES SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1204 WASHINGTON AVE STE 408
SAINT LOUIS MO
63103-1944
US

IV. Provider business mailing address

1204 WASHINGTON AVE STE 408
SAINT LOUIS MO
63103-1944
US

V. Phone/Fax

Practice location:
  • Phone: 314-354-6304
  • Fax: 314-354-6305
Mailing address:
  • Phone: 314-354-6304
  • Fax: 314-354-6305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number2017027668
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: