Provider Demographics
NPI:1528000700
Name:MCCAMMON, JEAN R (MSN, ANP-BC, ACNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:R
Last Name:MCCAMMON
Suffix:
Gender:F
Credentials:MSN, ANP-BC, ACNP-BC
Other - Prefix:MISS
Other - First Name:JEAN
Other - Middle Name:M
Other - Last Name:RENFRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSN, RN
Mailing Address - Street 1:12639 OLD TESSON RD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2786
Mailing Address - Country:US
Mailing Address - Phone:314-849-0311
Mailing Address - Fax:314-849-4423
Practice Address - Street 1:13319 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:DES PERES
Practice Address - State:MO
Practice Address - Zip Code:63131-1710
Practice Address - Country:US
Practice Address - Phone:314-822-1060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO137755363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO206587OtherBLUE CROSS BLUE SHIELD
MO733111OtherHEALTHLINK