Healthcare Provider Details

I. General information

NPI: 1689210924
Provider Name (Legal Business Name): JENNA MATTHEWS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNA CHARBONEAU

II. Dates (important events)

Enumeration Date: 11/21/2019
Last Update Date: 12/11/2023
Certification Date: 12/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10004 KENNERLY RD STE 374B
SAINT LOUIS MO
63128-2178
US

IV. Provider business mailing address

PO BOX 802841
KANSAS CITY MO
64180-2841
US

V. Phone/Fax

Practice location:
  • Phone: 314-842-9669
  • Fax: 314-842-1017
Mailing address:
  • Phone: 314-842-9669
  • Fax: 314-842-1017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number2019028561
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: