Basic Information
| Provider Information | |||||||||
| NPI: | 1700545654 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLEY | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BSN, RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | REKOWSKI | ||||||||
| OtherFirstName: | JEAN | ||||||||
| OtherMiddleName: | E | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1430 OLIVE ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631032303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142063700 | ||||||||
| FaxNumber: | 3142063708 | ||||||||
| Practice Location | |||||||||
| Address1: | 1150 GRAHAM RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | FLORISSANT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630318077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142063800 | ||||||||
| FaxNumber: | 3142093992 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2021 | ||||||||
| LastUpdateDate: | 12/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 2017044682 | MO | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.