Healthcare Provider Details

I. General information

NPI: 1003893785
Provider Name (Legal Business Name): JETUAN L ROWLEY-HERRON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JETUAN L ROWLEY

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 12/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5471 DR MARTIN LUTHER KING DR
SAINT LOUIS MO
63112-4265
US

IV. Provider business mailing address

5471 DR MARTIN LUTHER KING DR
SAINT LOUIS MO
63112-4265
US

V. Phone/Fax

Practice location:
  • Phone: 314-367-5820
  • Fax: 314-367-7010
Mailing address:
  • Phone: 314-367-5820
  • Fax: 314-367-7010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-111984
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036.111984
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2004020480
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: