Provider Demographics
NPI:1700230539
Name:FARRELL, JENNIFER (DO)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:FARRELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:LOOMIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:3 ST. ELIZABETH'S BLVD, STE. 4000
Mailing Address - Street 2:
Mailing Address - City:O'FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269
Mailing Address - Country:US
Mailing Address - Phone:618-256-7311
Mailing Address - Fax:618-222-4790
Practice Address - Street 1:3 ST. ELIZABETH'S BLVD, STE. 4000
Practice Address - Street 2:
Practice Address - City:O'FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269
Practice Address - Country:US
Practice Address - Phone:618-256-7311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-18
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036149493207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine