Provider Demographics
NPI:1861814261
Name:CIVELLO, JESSE MARIE (DPT)
Entity Type:Individual
Prefix:MRS
First Name:JESSE
Middle Name:MARIE
Last Name:CIVELLO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 S MERAMEC AVENUE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CLAYTON
Mailing Address - State:MO
Mailing Address - Zip Code:63105
Mailing Address - Country:US
Mailing Address - Phone:314-707-4179
Mailing Address - Fax:314-286-1473
Practice Address - Street 1:222 S MERAMEC AVENUE
Practice Address - Street 2:SUITE 100
Practice Address - City:CLAYTON
Practice Address - State:MO
Practice Address - Zip Code:63105
Practice Address - Country:US
Practice Address - Phone:314-707-4179
Practice Address - Fax:314-286-1473
Is Sole Proprietor?:No
Enumeration Date:2014-01-20
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013043933225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO480057326Medicaid