Provider Demographics
NPI:1619157799
Name:HUBER, JERRY
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:
Last Name:HUBER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 SPRING MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-3447
Mailing Address - Country:US
Mailing Address - Phone:314-220-4044
Mailing Address - Fax:
Practice Address - Street 1:743 SPIRIT 40 PARK DR
Practice Address - Street 2:STE 121
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005-1129
Practice Address - Country:US
Practice Address - Phone:314-220-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MONA171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor