Provider Demographics
NPI:1255951398
Name:KING BROGAN, JENNIFER DAYLE (CRADC, MARS, CH)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DAYLE
Last Name:KING BROGAN
Suffix:
Gender:F
Credentials:CRADC, MARS, CH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:197 CROSSWINDS DR
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MO
Mailing Address - Zip Code:63010-2018
Mailing Address - Country:US
Mailing Address - Phone:636-204-9766
Mailing Address - Fax:
Practice Address - Street 1:3309 S KINGSHIGHWAY BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-1101
Practice Address - Country:US
Practice Address - Phone:314-206-3708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-18
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO4111101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)