Basic Information
| Provider Information | |||||||||
| NPI: | 1235724956 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DRIEDGER | ||||||||
| FirstName: | JASON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12110 CLAYTON RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631312516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149898150 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4531 WEBER RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631235700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142568620 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2021 | ||||||||
| LastUpdateDate: | 03/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TS0200X | MO | Y | Behavioral Health & Social Service Providers | Psychologist | School |
No ID Information.