Basic Information
| Provider Information | |||||||||
| NPI: | 1619289311 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAUER | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ANDERSON | ||||||||
| OtherFirstName: | JACQUELINE | ||||||||
| OtherMiddleName: | L. | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 505164 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631505164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178294620 | ||||||||
| FaxNumber: | 4178294316 | ||||||||
| Practice Location | |||||||||
| Address1: | 1965 S FREMONT AVE | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658042201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178209055 | ||||||||
| FaxNumber: | 4178209056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2010 | ||||||||
| LastUpdateDate: | 04/04/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0402X | 2015021019 | MO | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
ID Information
| ID | Type | State | Issuer | Description | 201120190A | 05 | KS | MEDICAID | 210762001 | 05 | AR | MEDICAID | 1619289311 | 05 | MO | MEDICAID |