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General NPI Number Information
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NPI Number | 1508670449
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Entity Type | Individual
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Provider Name | MRS. JACQUELINE PETTY
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Gender | Female
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Dates
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Enumeration Date | 02/03/2025
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Last Update Date | 02/03/2025
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Provider Practice Location Address
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Address Line | 42 FOUR SEASONS SHOPPING CTR STE 111
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City | CHESTERFIELD
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State | MO
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Zip | 63017-3197
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Country | US
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Telephone | 314-884-0411
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Fax |
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Provider Business Mailing Address
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Address Line | 896 EMERALD PLACE DR
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City | SAINT CHARLES
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State | MO
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Zip | 63304-1091
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Country | US
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Telephone | 314-808-5639
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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 | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 2008017099
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License Number State | MO
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