Provider Demographics
NPI:1184613697
Name:OWEN, JEANNINE D (PHD)
Entity type:Individual
Prefix:DR
First Name:JEANNINE
Middle Name:D
Last Name:OWEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:56 ORCHARD LN
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-6945
Mailing Address - Country:US
Mailing Address - Phone:314-966-6638
Mailing Address - Fax:314-965-2326
Practice Address - Street 1:10000 WATSON RD
Practice Address - Street 2:SOUTH BUILDING STE S
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63126-1854
Practice Address - Country:US
Practice Address - Phone:314-966-6638
Practice Address - Fax:314-965-2326
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO00071103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO70235Medicare PIN