Healthcare Provider Details

I. General information

NPI: 1639468135
Provider Name (Legal Business Name): JENNIFER L. HEITHAUS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER LUKAC

II. Dates (important events)

Enumeration Date: 04/05/2011
Last Update Date: 05/04/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

PO BOX 503900
SAINT LOUIS MO
63150-3900
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-5609
  • Fax: 314-268-4028
Mailing address:
  • Phone: 314-577-5609
  • Fax: 314-268-4028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number2014007663
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2014007663
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: