Provider Demographics
NPI:1487426359
Name:FONVILLE-SIMMONS, JADA L
Entity type:Individual
Prefix:
First Name:JADA
Middle Name:L
Last Name:FONVILLE-SIMMONS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14748 FAON CT
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63034-2327
Mailing Address - Country:US
Mailing Address - Phone:217-520-0185
Mailing Address - Fax:
Practice Address - Street 1:14748 FAON CT
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63034-2327
Practice Address - Country:US
Practice Address - Phone:217-520-0185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-24
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula