Provider Demographics
NPI:1639642986
Name:HUMPHREY, JENNIFER M (APRN, FNP-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776084
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-3537
Mailing Address - Country:US
Mailing Address - Phone:314-831-8600
Mailing Address - Fax:314-831-0086
Practice Address - Street 1:637 DUNN RD STE 102A
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1755
Practice Address - Country:US
Practice Address - Phone:314-831-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018044467363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1639642986Medicaid