Healthcare Provider Details

I. General information

NPI: 1780409805
Provider Name (Legal Business Name): JESSICA MARIE KNOBBE CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2024
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 DELMAR BLVD STE B560
SAINT LOUIS MO
63112-3084
US

IV. Provider business mailing address

5501 DELMAR BLVD
SAINT LOUIS MO
63112-3054
US

V. Phone/Fax

Practice location:
  • Phone: 314-833-4030
  • Fax:
Mailing address:
  • Phone: 314-833-4030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2024047471
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: