Provider Demographics
NPI:1629217690
Name:HERNDON, JENNIFER RHAE (PA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:RHAE
Last Name:HERNDON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:RHAE
Other - Last Name:TWILLMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12101 WOODCREST EXECUTIVE DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5047
Mailing Address - Country:US
Mailing Address - Phone:314-317-0600
Mailing Address - Fax:
Practice Address - Street 1:300 1ST CAPITOL DR
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2844
Practice Address - Country:US
Practice Address - Phone:314-317-0600
Practice Address - Fax:314-317-0606
Is Sole Proprietor?:No
Enumeration Date:2009-02-13
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003430363A00000X
MO2009013843363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO150050018Medicare PIN
IL567730008Medicare PIN
MO132090005Medicare PIN
MO132130007Medicare PIN