Provider Demographics
NPI:1528020328
Name:ETLING, JENNIFER L (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:ETLING
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:DELAMIELLEURE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6 JUNGERMANN CIRCLE
Mailing Address - Street 2:STE 205
Mailing Address - City:ST PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376
Mailing Address - Country:US
Mailing Address - Phone:636-441-2122
Mailing Address - Fax:636-441-5290
Practice Address - Street 1:6 JUNGERMANN CIRCLE
Practice Address - Street 2:STE 205
Practice Address - City:ST PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376
Practice Address - Country:US
Practice Address - Phone:636-441-2122
Practice Address - Fax:636-441-5290
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005000203208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
165817OtherBLUE SHIELD
MO209370105Medicaid
M6725OtherMEDICARE ARKANSAS
165817OtherBLUE CHOICE
4309109800OtherPRODENTIAL
017283OtherEXCLUSIVE CHOICE
12593OtherESSENCE
231210OtherGHP
P00195292OtherRAILROAD MEDICARE
1700267OtherUNITED HEALTHCARE
487573OtherHEALTHLINK
7986366OtherAETNA
H74520OtherMERCY
165817OtherBLUE SHIELD
H74520OtherMERCY