Healthcare Provider Details

I. General information

NPI: 1831432814
Provider Name (Legal Business Name): JENNIFER LYNN TIETJEN CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2013
Last Update Date: 07/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12348 OLD TESSON RD ST 160
SAINT LOUIS MO
63128-2251
US

IV. Provider business mailing address

271 ARBOR TRAILS DR
BALLWIN MO
63021-3308
US

V. Phone/Fax

Practice location:
  • Phone: 314-467-3800
  • Fax:
Mailing address:
  • Phone: 314-753-3982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2013006671
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: