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General NPI Number Information
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NPI Number | 1053919118
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Entity Type | Individual
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Provider Name | JESSICA CLAIRE LUTKER APRN
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Gender | Female
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Dates
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Enumeration Date | 10/12/2020
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Last Update Date | 10/22/2020
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Provider Practice Location Address
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Address Line | 10012 KENNERLY RD STE 400
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City | SAINT LOUIS
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State | MO
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Zip | 63128-2197
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Country | US
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Telephone | 314-543-5999
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Fax | 314-543-5994
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Provider Business Mailing Address
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Address Line | 1223 N RAPP AVE
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City | COLUMBIA
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State | IL
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Zip | 62236-1125
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Country | US
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Telephone | 618-340-1869
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | 2020034593
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 2014039582
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License Number State | MO
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