=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710185392
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSE DAYA VRECENAK MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2007
-----------------------------------------------------
Last Update Date | 04/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 CHILDRENS PL DIV SURG PED, STE 2A
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63110-1002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-454-6022
-----------------------------------------------------
Fax | 866-422-8308
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7412011
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60674-2011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-454-6022
-----------------------------------------------------
Fax | 866-422-8308
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0120X
-----------------------------------------------------
Taxonomy Name | Pediatric Surgery Physician
-----------------------------------------------------
License Number | 2017025963
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------