Provider Demographics
NPI:1598845877
Name:BOOTH, JO ANN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JO
Middle Name:ANN
Last Name:BOOTH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S KINGSHIGHWAY ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-1637
Mailing Address - Country:US
Mailing Address - Phone:636-949-2650
Mailing Address - Fax:636-949-2650
Practice Address - Street 1:200 S KINGSHIGHWAY ST
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-1637
Practice Address - Country:US
Practice Address - Phone:636-949-2650
Practice Address - Fax:636-949-2650
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0046351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO99393746OtherPROVIDER ID
MO159912OtherPROVIDER ID
MO498219104Medicaid
MO465182OtherPROVIDER ID
MO494785314Medicare ID - Type Unspecified