Healthcare Provider Details

I. General information

NPI: 1083618904
Provider Name (Legal Business Name): FARRIS JACKSON JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 02/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11200 TESSON FERRY RD. STE 100
ST LOUIS MO
63123-6922
US

IV. Provider business mailing address

11200 TESSON FERRY RD. STE 100
ST LOUIS MO
63123-6922
US

V. Phone/Fax

Practice location:
  • Phone: 314-849-1500
  • Fax: 314-849-8789
Mailing address:
  • Phone: 314-849-1500
  • Fax: 314-849-8789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberR9F09
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: