Provider Demographics
NPI: | 1760018774 |
---|---|
Name: | JESSICA WHELAN LLC |
Entity Type: | Organization |
Organization Name: | JESSICA WHELAN LLC |
Other - Org Name: | HOLON INCLUSIVE HEALTH SYSTEM |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | CEO |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | JESSICA |
Authorized Official - Middle Name: | ANN |
Authorized Official - Last Name: | WHELAN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 314-470-1220 |
Mailing Address - Street 1: | PO BOX 242 |
Mailing Address - Street 2: | |
Mailing Address - City: | GROVER |
Mailing Address - State: | MO |
Mailing Address - Zip Code: | 63040-0242 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 636-236-5128 |
Mailing Address - Fax: | 636-242-5095 |
Practice Address - Street 1: | 207 N MAIN ST STE 109B |
Practice Address - Street 2: | |
Practice Address - City: | COLUMBIA |
Practice Address - State: | IL |
Practice Address - Zip Code: | 62236-1755 |
Practice Address - Country: | US |
Practice Address - Phone: | 314-470-1220 |
Practice Address - Fax: | 833-914-0432 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2020-03-21 |
Last Update Date: | 2021-11-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 174400000X | Other Service Providers | Specialist | Group - Multi-Specialty | |
No | 101Y00000X | Behavioral Health & Social Service Providers | Counselor | Group - Multi-Specialty | |
No | 103TC1900X | Behavioral Health & Social Service Providers | Psychologist | Counseling | Group - Multi-Specialty |
No | 103TP2701X | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | Group - Multi-Specialty |
No | 171M00000X | Other Service Providers | Case Manager/Care Coordinator | Group - Multi-Specialty | |
No | 183500000X | Pharmacy Service Providers | Pharmacist | Group - Multi-Specialty | |
No | 2083P0901X | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine | Group - Multi-Specialty |
No | 2084A0401X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine | Group - Multi-Specialty |
No | 2084B0040X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Behavioral Neurology & Neuropsychiatry | Group - Multi-Specialty |
No | 2084P0301X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Brain Injury Medicine | Group - Multi-Specialty |
No | 2084P0804X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | Group - Multi-Specialty |
No | 251J00000X | Agencies | Nursing Care | Group - Multi-Specialty | |
No | 253Z00000X | Agencies | In Home Supportive Care | Group - Multi-Specialty | |
No | 261QM1300X | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | Group - Multi-Specialty |
No | 261QR1100X | Ambulatory Health Care Facilities | Clinic/Center | Research | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
ID | 735518 | Other | MCKESSON SUBMITTER ID |
MO | 500089936 | Medicaid | |
MO | 6982159 | Other | AETNA - MEDICAID |