Basic Information
| Provider Information | |||||||||
| NPI: | 1326785924 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLS | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | TAYLOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12680 OLIVE BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631416322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142518888 | ||||||||
| FaxNumber: | 3142518889 | ||||||||
| Practice Location | |||||||||
| Address1: | 12680 OLIVE BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631416322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142518888 | ||||||||
| FaxNumber: | 3142518889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2022 | ||||||||
| LastUpdateDate: | 07/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2022023397 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.