Provider Demographics
NPI:1396763082
Name:SHORT, JEANNE S (PNP)
Entity type:Individual
Prefix:MS
First Name:JEANNE
Middle Name:S
Last Name:SHORT
Suffix:
Gender:F
Credentials:PNP
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Mailing Address - Street 1:1413 WENTZVILLE PKWY
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-3407
Mailing Address - Country:US
Mailing Address - Phone:636-332-5400
Mailing Address - Fax:636-332-5404
Practice Address - Street 1:1413 WENTZVILLE PKWY
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3407
Practice Address - Country:US
Practice Address - Phone:636-332-5400
Practice Address - Fax:636-332-5404
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO073396363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
Q29845Medicare UPIN
IL$$$$$$$$$001Medicaid