Provider Demographics
NPI:1982642609
Name:GILSTRAP, JEAN A (MD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:A
Last Name:GILSTRAP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JEAN
Other - Middle Name:A
Other - Last Name:SMITH-WOOLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:126 MISSOURI AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LEONARD WOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65473-8952
Mailing Address - Country:US
Mailing Address - Phone:573-596-0522
Mailing Address - Fax:
Practice Address - Street 1:126 MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473-8952
Practice Address - Country:US
Practice Address - Phone:573-596-0522
Practice Address - Fax:573-302-4413
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO072512084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207959818Medicaid
MOG00563Medicare UPIN
MO207959818Medicaid