Provider Demographics
NPI:1033121645
Name:LUCAS, JEANNIE A (MSN FNP)
Entity Type:Individual
Prefix:
First Name:JEANNIE
Middle Name:A
Last Name:LUCAS
Suffix:
Gender:F
Credentials:MSN FNP
Other - Prefix:
Other - First Name:JEANNIE
Other - Middle Name:A
Other - Last Name:RODERICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:573-815-7119
Mailing Address - Fax:573-815-7116
Practice Address - Street 1:1605 E BROADWAY
Practice Address - Street 2:SUITE 302
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8023
Practice Address - Country:US
Practice Address - Phone:573-815-7119
Practice Address - Fax:573-815-7116
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO095253363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO127400001Medicare PIN