Healthcare Provider Details

I. General information

NPI: 1902073299
Provider Name (Legal Business Name): WILLIAM B JENNINGS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2008
Last Update Date: 05/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78 KENRICK PLZ
SAINT LOUIS MO
63119-4414
US

IV. Provider business mailing address

78 KENRICK PLZ
SAINT LOUIS MO
63119-4414
US

V. Phone/Fax

Practice location:
  • Phone: 314-962-8020
  • Fax: 314-962-6570
Mailing address:
  • Phone: 314-962-8020
  • Fax: 314-962-6570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberTR00008
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: