1962460428 NPI number — JSM ENTERPRISES, LLC

Table of content: (NPI 1962460428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962460428 NPI number — JSM ENTERPRISES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JSM ENTERPRISES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962460428
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 796002
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63179-6000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-567-4449
Provider Business Mailing Address Fax Number:
314-567-0762

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
450 N NEW BALLAS RD
Provider Second Line Business Practice Location Address:
STE. 250
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63141-6835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-567-4449
Provider Business Practice Location Address Fax Number:
314-567-0762
Provider Enumeration Date:
05/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MODICA
Authorized Official First Name:
SHARON
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
314-567-5445

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 261QR0206X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 189278 . This is a "GROUP HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8351165 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 193989 . This is a "BCBS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 0635411 OR 0668136 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 10439 . This is a "ESSENCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: A-33594 . This is a "MULTIPLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 237811 . This is a "HEALTHLINK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 113199 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 44935 . This is a "HEALTHCARE USA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 852262 . This is a "FIRST HEALTH" identifier . This identifiers is of the category "OTHER".




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