Basic Information
| Provider Information | |||||||||
| NPI: | 1629092408 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MASSONI | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 S EUCLID AVE | ||||||||
| Address2: | CB 8052 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144548917 | ||||||||
| FaxNumber: | 3144545571 | ||||||||
| Practice Location | |||||||||
| Address1: | 4921 PARKVIEW PL | ||||||||
| Address2: | STE 8B | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144548917 | ||||||||
| FaxNumber: | 3144545571 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 11/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 153985 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 428330815 | 05 | MO | MEDICAID |