Basic Information
| Provider Information | |||||||||
| NPI: | 1700202959 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRADEL | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23340 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631563340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148511000 | ||||||||
| FaxNumber: | 3148514445 | ||||||||
| Practice Location | |||||||||
| Address1: | 1343 NE SERVICE RD | ||||||||
| Address2: | |||||||||
| City: | WARRENTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633831387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148511000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2014 | ||||||||
| LastUpdateDate: | 06/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 2014007464 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 420012618 | 05 | MO | MEDICAID |