Provider Demographics
NPI:1902460173
Name:STALEY, JENNIFER (ACNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:STALEY
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:BERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:621 S NEW BALLAS RD STE 560A
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8261
Mailing Address - Country:US
Mailing Address - Phone:314-251-6440
Mailing Address - Fax:
Practice Address - Street 1:621 S NEW BALLAS RD STE 560A
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8261
Practice Address - Country:US
Practice Address - Phone:314-251-6440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019006497363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care