Healthcare Provider Details

I. General information

NPI: 1356755201
Provider Name (Legal Business Name): JESSICA ELLIE MA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2014
Last Update Date: 01/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 S KINGSHIGHWAY BLVD FL 6 6TH FLOOR
SAINT LOUIS MO
63110-1026
US

IV. Provider business mailing address

660 S EUCLID AVE C B 8121
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-5060
  • Fax: 314-362-6959
Mailing address:
  • Phone: 314-454-8082
  • Fax: 314-362-7491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number2016029095
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: