Healthcare Provider Details

I. General information

NPI: 1124829833
Provider Name (Legal Business Name): JORDAN KING
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2025
Last Update Date: 03/20/2025
Certification Date: 03/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6420 CLAYTON RD
SAINT LOUIS MO
63117-1811
US

IV. Provider business mailing address

1157 N MOORE ST
WATERLOO IL
62298-5409
US

V. Phone/Fax

Practice location:
  • Phone: 618-604-2833
  • Fax:
Mailing address:
  • Phone: 618-604-2833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number2015036804
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: