Healthcare Provider Details

I. General information

NPI: 1295255115
Provider Name (Legal Business Name): JESSICA GRUBER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JESSICA PIONTEK MD

II. Dates (important events)

Enumeration Date: 06/21/2017
Last Update Date: 11/17/2022
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10012 KENNERLY RD STE 401
SAINT LOUIS MO
63128-2197
US

IV. Provider business mailing address

10012 KENNERLY RD STE 401
SAINT LOUIS MO
63128-2197
US

V. Phone/Fax

Practice location:
  • Phone: 314-842-5660
  • Fax:
Mailing address:
  • Phone: 314-842-5660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2021022164
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2017020337
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: