Provider Demographics
NPI:1669696647
Name:HERRON, JENNIFER KAY
Entity type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:KAY
Last Name:HERRON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 N MCKNIGHT RD
Mailing Address - Street 2:APT B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-4931
Mailing Address - Country:US
Mailing Address - Phone:314-692-2494
Mailing Address - Fax:
Practice Address - Street 1:801 N 11TH ST
Practice Address - Street 2:MEDICAID DEPARTMENT
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63101-1015
Practice Address - Country:US
Practice Address - Phone:314-345-2535
Practice Address - Fax:314-345-2653
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003000562225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics