Basic Information
| Provider Information | |||||||||
| NPI: | 1811316276 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CHILDRENS PL | ||||||||
| Address2: | MSC 8515-87-1200 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144542683 | ||||||||
| FaxNumber: | 3144544633 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 CHILDRENS PL | ||||||||
| Address2: | DIV PED NEWBORN MEDICINE | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144542683 | ||||||||
| FaxNumber: | 3144544633 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2014 | ||||||||
| LastUpdateDate: | 11/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 2017022852 | MO | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 200029277 | 05 | MO | MEDICAID |