Provider Demographics
NPI:1568250785
Name:MASTROIANNI, JACLYN ANNE
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:ANNE
Last Name:MASTROIANNI
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 1:896 BURGUNDY LN
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MO
Mailing Address - Zip Code:63011-3587
Mailing Address - Country:US
Mailing Address - Phone:314-856-3363
Mailing Address - Fax:
Practice Address - Street 1:896 BURGUNDY LN
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:MO
Practice Address - Zip Code:63011-3587
Practice Address - Country:US
Practice Address - Phone:314-856-3363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-28
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO819677101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor