Healthcare Provider Details

I. General information

NPI: 1588368500
Provider Name (Legal Business Name): JADE HENCKEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD STE 7005
SAINT LOUIS MO
63141-8232
US

IV. Provider business mailing address

PO BOX 825159
PHILADELPHIA PA
19182-5159
US

V. Phone/Fax

Practice location:
  • Phone: 314-507-4064
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number2026030547
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: