Healthcare Provider Details

I. General information

NPI: 1447745500
Provider Name (Legal Business Name): JERI A DOCKINS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2018
Last Update Date: 07/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10010 KENNERLY RD
SAINT LOUIS MO
63128
US

IV. Provider business mailing address

PO BOX 22407
SAINT LOUIS MO
63126-0407
US

V. Phone/Fax

Practice location:
  • Phone: 636-386-7222
  • Fax: 636-200-4036
Mailing address:
  • Phone: 636-386-7222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2018022928
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: