Provider Demographics
NPI:1497192785
Name:HANISCH, JESSE JOE (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:JESSE
Middle Name:JOE
Last Name:HANISCH
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1400 US HIGHWAY 61 STE 310
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-4141
Mailing Address - Country:US
Mailing Address - Phone:636-543-2140
Mailing Address - Fax:636-933-1085
Practice Address - Street 1:1400 US HIGHWAY 61 STE 310
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4141
Practice Address - Country:US
Practice Address - Phone:636-543-2140
Practice Address - Fax:636-933-1085
Is Sole Proprietor?:No
Enumeration Date:2013-05-28
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036154307208600000X
MO2024041767208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery