Individual
RENITRA JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
FNP
Contact information
Practice address
637 DUNN RD STE 102A, HAZELWOOD, MO 63042-1755
(314) 831-8600
(314) 839-5596
Mailing address
PO BOX 776084, CHICAGO, IL 60677-0019
(314) 831-8600
(314) 831-0086
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
2000164715
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2000164715
—
MO
Enumeration date
11/06/2006
Last updated
08/16/2024
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