Provider Demographics
NPI:1003893785
Name:ROWLEY-HERRON, JETUAN L (MD)
Entity Type:Individual
Prefix:MRS
First Name:JETUAN
Middle Name:L
Last Name:ROWLEY-HERRON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JETUAN
Other - Middle Name:L
Other - Last Name:ROWLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5471 DR MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-4265
Mailing Address - Country:US
Mailing Address - Phone:314-367-5820
Mailing Address - Fax:314-367-7010
Practice Address - Street 1:5471 DR MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-4265
Practice Address - Country:US
Practice Address - Phone:314-367-5820
Practice Address - Fax:314-367-7010
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-111984207Q00000X
IL036.111984207QS0010X
MO2004020480207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036111984Medicaid
ILK11742Medicare ID - Type Unspecified
IL036111984Medicaid