Healthcare Provider Details

I. General information

NPI: 1639642986
Provider Name (Legal Business Name): JENNIFER M HUMPHREY APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2019
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 JUNGERMANN CIR STE 201
SAINT PETERS MO
63376-1619
US

IV. Provider business mailing address

'PO BOX 959354 ST LOUIS MO 63195'
SAINT LOUIS MO
63195-0001
US

V. Phone/Fax

Practice location:
  • Phone: 636-344-1073
  • Fax: 636-916-9953
Mailing address:
  • Phone: 636-344-1073
  • Fax: 636-916-9953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2018044467
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2018044467
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: