Basic Information
| Provider Information | |||||||||
| NPI: | 1831458033 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'MALLEY | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D, | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1050 W 10TH ST | ||||||||
| Address2: | |||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654012905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733649000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 N JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | SAINT JAMES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732658840 | ||||||||
| FaxNumber: | 5732658884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2012 | ||||||||
| LastUpdateDate: | 08/22/2019 | ||||||||
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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 | 207Q00000X | 2015020983 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.