Provider Demographics
NPI:1699811984
Name:SHUH, JODIE RAE (MOT)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:RAE
Last Name:SHUH
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 ORIOLE PL
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63144-1126
Mailing Address - Country:US
Mailing Address - Phone:573-225-2168
Mailing Address - Fax:636-928-2862
Practice Address - Street 1:2561 ABBYDALE DR
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-3018
Practice Address - Country:US
Practice Address - Phone:636-928-3760
Practice Address - Fax:636-928-2862
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006003000171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor