Basic Information
| Provider Information | |||||||||
| NPI: | 1710498167 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUTLIN | ||||||||
| FirstName: | JERISHA | ||||||||
| MiddleName: | LACRAE | ||||||||
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| Credential: | LPC, NCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9100 OVERLAND PLZ | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631146123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147449027 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9100 OVERLAND PLZ | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631146123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147449027 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2017 | ||||||||
| LastUpdateDate: | 10/12/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 2015006047 | MO | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.