Provider Demographics
NPI:1689993164
Name:EVANS, JENNIFER LYNN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:EVANS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2451 EXECUTIVE DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-5606
Mailing Address - Country:US
Mailing Address - Phone:636-300-9922
Mailing Address - Fax:636-300-9922
Practice Address - Street 1:2451 EXECUTIVE DR
Practice Address - Street 2:SUITE 103
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-5606
Practice Address - Country:US
Practice Address - Phone:636-300-9922
Practice Address - Fax:636-300-9922
Is Sole Proprietor?:No
Enumeration Date:2010-05-24
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002011125103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical