Provider Demographics
NPI:1689210924
Name:MATTHEWS, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:
Other - Last Name:CHARBONEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 802841
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-2841
Mailing Address - Country:US
Mailing Address - Phone:314-842-9669
Mailing Address - Fax:314-842-1017
Practice Address - Street 1:10004 KENNERLY RD STE 374B
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2178
Practice Address - Country:US
Practice Address - Phone:314-842-9669
Practice Address - Fax:314-842-1017
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-21
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019028561363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AG06190154OtherAMERICAN ACADEMY OF NURSE PRACTITIONERS