Healthcare Provider Details

I. General information

NPI: 1770119976
Provider Name (Legal Business Name): JENNIFER HENDRIX FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2020
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 VISTA AVE
SAINT LOUIS MO
63110-2539
US

IV. Provider business mailing address

16438 AUDUBON VILLAGE DR
WILDWOOD MO
63040-1720
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2018029910
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: