Provider Demographics
NPI:1831117647
Name:MICHENER, JANE K (CPNP)
Entity Type:Individual
Prefix:MS
First Name:JANE
Middle Name:K
Last Name:MICHENER
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:MS
Other - First Name:JANE
Other - Middle Name:K
Other - Last Name:ROETTGER(MAIDEN NAME)
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 8500, LOCKBOX 7642
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-7642
Mailing Address - Country:US
Mailing Address - Phone:813-281-8115
Mailing Address - Fax:813-281-8656
Practice Address - Street 1:4400 CLAYTON AVENUE
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110
Practice Address - Country:US
Practice Address - Phone:314-432-3600
Practice Address - Fax:314-872-8309
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO140451363L00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
180798OtherMO-BLUE SHIELD
180798OtherMO-BLUE SHIELD