Provider Demographics
NPI:1689737595
Name:PINGEL, JODI GLAUS (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JODI
Middle Name:GLAUS
Last Name:PINGEL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:JODI
Other - Middle Name:RAE
Other - Last Name:GLAUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:300 OZARK TRAIL DRIVE
Mailing Address - Street 2:SUITE 217
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63011
Mailing Address - Country:US
Mailing Address - Phone:636-891-9760
Mailing Address - Fax:636-891-9765
Practice Address - Street 1:300 OZARK TRAIL DRIVE
Practice Address - Street 2:SUITE 217
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011
Practice Address - Country:US
Practice Address - Phone:636-891-9760
Practice Address - Fax:636-891-9765
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003030079103TB0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO990001259Medicare UPIN