Provider Demographics
NPI:1619574936
Name:BOOKER, JESSICA MARIE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:BOOKER
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 1:8350 STATE ROUTE 30
Mailing Address - Street 2:
Mailing Address - City:DITTMER
Mailing Address - State:MO
Mailing Address - Zip Code:63023-1909
Mailing Address - Country:US
Mailing Address - Phone:636-707-2097
Mailing Address - Fax:
Practice Address - Street 1:6403 STAR BUCK DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-7836
Practice Address - Country:US
Practice Address - Phone:314-229-9224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-08
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008018755163WP0808X
MO2021002799363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health