Basic Information
| Provider Information | |||||||||
| NPI: | 1790100089 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLDHAM | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | |||||||||
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| Credential: | CPNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HUESGEN | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1203 SMIZER MILL RD | ||||||||
| Address2: | |||||||||
| City: | FENTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630263483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6367171350 | ||||||||
| FaxNumber: | 6367171355 | ||||||||
| Practice Location | |||||||||
| Address1: | 1203 SMIZER MILL RD | ||||||||
| Address2: | |||||||||
| City: | FENTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630263483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6367171350 | ||||||||
| FaxNumber: | 6367171355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2014 | ||||||||
| LastUpdateDate: | 02/24/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 2013037116 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.