Provider Demographics
NPI:1851495907
Name:GARRETT, JACQUELYN B (MD)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:B
Last Name:GARRETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:B
Other - Last Name:DILWORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:11125 DUNN RD STE 411
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6132
Mailing Address - Country:US
Mailing Address - Phone:314-355-7111
Mailing Address - Fax:314-355-8604
Practice Address - Street 1:11125 DUNN RD
Practice Address - Street 2:STE 411
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6132
Practice Address - Country:US
Practice Address - Phone:314-355-7111
Practice Address - Fax:314-355-8604
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4G86207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203880802Medicaid
MO203880802Medicaid
A13964Medicare UPIN