Healthcare Provider Details

I. General information

NPI: 1649840711
Provider Name (Legal Business Name): MRS. JENNIFER MASSIMINO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N 11TH ST
SAINT LOUIS MO
63101-1015
US

IV. Provider business mailing address

12856 HAW THICKET LN
SAINT LOUIS MO
63131-2132
US

V. Phone/Fax

Practice location:
  • Phone: 314-633-5300
  • Fax:
Mailing address:
  • Phone: 314-821-1953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number118744
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: