Healthcare Provider Details

I. General information

NPI: 1669696647
Provider Name (Legal Business Name): MISS JENNIFER KAY HERRON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

721 N MCKNIGHT RD APT B
SAINT LOUIS MO
63132-4931
US

V. Phone/Fax

Practice location:
  • Phone: 314-345-2535
  • Fax: 314-345-2653
Mailing address:
  • Phone: 314-692-2494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number2003000562
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: