Healthcare Provider Details

I. General information

NPI: 1619535762
Provider Name (Legal Business Name): JKLM MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2019
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11144 TESSON FERRY RD STE 100
SAINT LOUIS MO
63123-6965
US

IV. Provider business mailing address

11144 TESSON FERRY RD STE 100
SAINT LOUIS MO
63123-6965
US

V. Phone/Fax

Practice location:
  • Phone: 314-842-1441
  • Fax: 314-842-1439
Mailing address:
  • Phone: 314-842-1441
  • Fax: 314-842-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number
License Number State

VIII. Authorized Official

Name: JANELLE SHEEN
Title or Position: PRESIDENT
Credential:
Phone: 314-842-1441