Healthcare Provider Details

I. General information

NPI: 1639810005
Provider Name (Legal Business Name): JAMIE ELISE HANSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2022
Last Update Date: 04/07/2022
Certification Date: 04/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 S GRAND BLVD
SAINT LOUIS MO
63104-1004
US

IV. Provider business mailing address

4041 CHOUTEAU AVE APT 141
SAINT LOUIS MO
63110-1739
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-9853
  • Fax: 314-977-9852
Mailing address:
  • Phone: 248-622-9090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: