Healthcare Provider Details

I. General information

NPI: 1053657924
Provider Name (Legal Business Name): JAZZ HAIR INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2012
Last Update Date: 01/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 COOK AVE
SAINT LOUIS MO
63113-3402
US

IV. Provider business mailing address

3950 COOK AVE
SAINT LOUIS MO
63113
US

V. Phone/Fax

Practice location:
  • Phone: 314-258-7061
  • Fax:
Mailing address:
  • Phone: 314-258-7061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State

VIII. Authorized Official

Name: KELLEY JORDAN
Title or Position: COSMETOLOGIST
Credential:
Phone: 314-389-5770