Provider Demographics
NPI:1720058381
Name:HELTON, JESSE DWAYNE (DO)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:DWAYNE
Last Name:HELTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:DWAYNE
Other - Middle Name:
Other - Last Name:HELTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:1400 US HIGHWAY 61
Mailing Address - Street 2:SUITE 250
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-4100
Mailing Address - Country:US
Mailing Address - Phone:636-543-2420
Mailing Address - Fax:636-543-2421
Practice Address - Street 1:1400 US HIGHWAY 61
Practice Address - Street 2:SUITE 250
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4100
Practice Address - Country:US
Practice Address - Phone:636-543-2420
Practice Address - Fax:636-543-2421
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODO113093207R00000X
MO261QF0400X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1477800340Medicaid
MO1891040077Medicaid
MO595379306Medicaid
MO244981205Medicaid
MO595379314Medicaid
MO1891040077Medicaid
MO000094772Medicare PIN
MO595379306Medicaid
MO261063Medicare UPIN
MO1477800340Medicaid