Provider Demographics
NPI:1598136483
Name:SIMMONS, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SIMMONS
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 1:5239 MARDEL AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-1760
Mailing Address - Country:US
Mailing Address - Phone:314-707-0644
Mailing Address - Fax:
Practice Address - Street 1:5239 MARDEL AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-1760
Practice Address - Country:US
Practice Address - Phone:314-707-0644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-17
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74737101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional