MEDICARE: JENNIFER K HASAK PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	R0021	MO

General Provider Information

NPI Number	:	1881677524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER K HASAK PH.D.

Provider Business Mailing Address
First Line	:	313 ALTUS PL
Second Line	:
City	:	KIRKWOOD
State	:	MO
Zip	:	63122-5402
Country	:	US
Telephone Number	:	314-965-6311
Fax Number	:	314-569-0605

Provider Business Practice Location Address
First Line	:	777 S NEW BALLAS RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-8705
Country	:	US
Telephone Number	:	314-569-0655
Fax Number	:	314-569-0605

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/28/2005
Last Update Date	:	07/09/2007

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