Healthcare Provider Details

I. General information

NPI: 1275774077
Provider Name (Legal Business Name): JACKIE R GOOSTREE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2009
Last Update Date: 03/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 VETERANS MEMORIAL PKWY STE 100
SAINT PETERS MO
63376-1681
US

IV. Provider business mailing address

20 PARKVIEW DR
SAINT PETERS MO
63376-2919
US

V. Phone/Fax

Practice location:
  • Phone: 636-441-0906
  • Fax: 636-928-9288
Mailing address:
  • Phone: 636-441-0906
  • Fax: 636-928-9288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: