Provider Demographics
NPI:1184051625
Name:KISTER, JESSICA C (AA-C)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:C
Last Name:KISTER
Suffix:
Gender:F
Credentials:AA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:C
Other - Last Name:HAHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AA-C
Mailing Address - Street 1:PO BOX 22407
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63126-0407
Mailing Address - Country:US
Mailing Address - Phone:636-386-7222
Mailing Address - Fax:636-200-4036
Practice Address - Street 1:10010 KENNERLY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2106
Practice Address - Country:US
Practice Address - Phone:636-386-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-30
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013035993367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1184051625Medicaid
MO132300607Medicare PIN
MO1184051625Medicaid