Provider Demographics
NPI:1154445534
Name:BAKER, JACQUELYNN DANIELLE (PA)
Entity type:Individual
Prefix:
First Name:JACQUELYNN
Middle Name:DANIELLE
Last Name:BAKER
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:JACQUELYNN
Other - Middle Name:DANIELLE
Other - Last Name:BERUMEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:915 N GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63106-1621
Mailing Address - Country:US
Mailing Address - Phone:314-652-4100
Mailing Address - Fax:143-289-7058
Practice Address - Street 1:915 N GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63106-1621
Practice Address - Country:US
Practice Address - Phone:314-652-4100
Practice Address - Fax:314-289-7058
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO114211363A00000X
IL085004581363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S48241Medicare UPIN