Individual
TRAVIS WILEY JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
621 S NEW BALLAS RD STE 3019B, SAINT LOUIS, MO 63141-8267
(314) 509-5305
(314) 251-4454
Mailing address
621 S NEW BALLAS RD STE 3019B, SAINT LOUIS, MO 63141-8267
(314) 509-5305
(314) 251-4454
Taxonomy
Speciality
Code
Description
License number
State
390200000X
Student in an Organized Health Care Education/Training Program
Primary
—
MO
Other
Enumeration date
04/06/2026
Last updated
04/06/2026
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