Healthcare Provider Details

I. General information

NPI: 1508980541
Provider Name (Legal Business Name): JAN MIRIAM JACOB-WICKLAND PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 02/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S NEW BALLAS RD DEPT OF
SAINT LOUIS MO
63141-8221
US

IV. Provider business mailing address

1054 BIG BEND STATION DR
MANCHESTER MO
63088-1429
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6000
  • Fax: 636-386-7679
Mailing address:
  • Phone: 636-861-1102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number119559
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: