Basic Information
| Provider Information | |||||||||
| NPI: | 1891809646 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCFADDEN | ||||||||
| FirstName: | JACQUELYN | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11642 W FLORISSANT AVE | ||||||||
| Address2: | |||||||||
| City: | FLORISSANT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630336723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148388220 | ||||||||
| FaxNumber: | 3148384007 | ||||||||
| Practice Location | |||||||||
| Address1: | 11642 W FLORISSANT AVE | ||||||||
| Address2: | |||||||||
| City: | FLORISSANT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630336723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148388220 | ||||||||
| FaxNumber: | 3148384007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 11/21/2014 | ||||||||
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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 | 207R00000X | 2006024763 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.