Provider Demographics
NPI:1215560834
Name:TUGGLE, JERLINE
Entity Type:Individual
Prefix:
First Name:JERLINE
Middle Name:
Last Name:TUGGLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 PAPIN ST STE 109
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-3132
Mailing Address - Country:US
Mailing Address - Phone:314-690-9995
Mailing Address - Fax:314-558-2600
Practice Address - Street 1:1310 PAPIN ST STE 109
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-3132
Practice Address - Country:US
Practice Address - Phone:314-690-9995
Practice Address - Fax:314-558-2600
Is Sole Proprietor?:No
Enumeration Date:2020-02-21
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101799225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101779Medicaid