Provider Demographics
NPI:1114368511
Name:CHAMPAGNE, JESSE AARON
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:AARON
Last Name:CHAMPAGNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:STE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:573-815-6631
Mailing Address - Fax:573-815-6634
Practice Address - Street 1:900 W NIFONG BLVD
Practice Address - Street 2:STE 101
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-4467
Practice Address - Country:US
Practice Address - Phone:573-815-6631
Practice Address - Fax:573-815-6634
Is Sole Proprietor?:No
Enumeration Date:2013-07-13
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07350363LF0000X
MO2016004506363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily