Provider Demographics
NPI:1275774077
Name:GOOSTREE, JACKIE R
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:R
Last Name:GOOSTREE
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 1:20 PARKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-2919
Mailing Address - Country:US
Mailing Address - Phone:636-441-0906
Mailing Address - Fax:636-928-9288
Practice Address - Street 1:5401 VETERANS MEMORIAL PKWY STE 100
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1681
Practice Address - Country:US
Practice Address - Phone:636-441-0906
Practice Address - Fax:636-928-9288
Is Sole Proprietor?:No
Enumeration Date:2009-03-09
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist