Provider Demographics
NPI:1801147962
Name:CARR, JACQUELINE LEE (ANP)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:LEE
Last Name:CARR
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12990 MANCHESTER ROAD
Mailing Address - Street 2:101
Mailing Address - City:DES PERES
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1860
Mailing Address - Country:US
Mailing Address - Phone:314-567-3567
Mailing Address - Fax:314-567-6575
Practice Address - Street 1:12990 MANCHESTER RD
Practice Address - Street 2:101
Practice Address - City:DES PERES
Practice Address - State:MO
Practice Address - Zip Code:63131-1860
Practice Address - Country:US
Practice Address - Phone:314-567-3567
Practice Address - Fax:314-567-6575
Is Sole Proprietor?:No
Enumeration Date:2012-09-28
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012015191363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health