Provider Demographics
NPI:1093947863
Name:KWON, JENNIE H (DO)
Entity Type:Individual
Prefix:DR
First Name:JENNIE
Middle Name:H
Last Name:KWON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-362-9098
Mailing Address - Fax:314-362-9851
Practice Address - Street 1:620 S TAYLOR AVE
Practice Address - Street 2:DIV IM INFECTIOUS DISEASE, STE 100
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1035
Practice Address - Country:US
Practice Address - Phone:314-362-9098
Practice Address - Fax:314-362-9851
Is Sole Proprietor?:No
Enumeration Date:2009-08-12
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2015026174207RI0200X
MO2013018626207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200027365Medicaid