Provider Demographics
NPI:1720421175
Name:HERTER, JENNIFER SHINE (ANP-C)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:SHINE
Last Name:HERTER
Suffix:
Gender:
Credentials:ANP-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:SHINE
Other - Last Name:MIDDENDORF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 BRONZE POINTE BLVD STE 1A
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-1045
Mailing Address - Country:US
Mailing Address - Phone:618-233-7055
Mailing Address - Fax:618-233-9055
Practice Address - Street 1:11125 DUNN RD STE 100
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6132
Practice Address - Country:US
Practice Address - Phone:314-653-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-15
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010646363L00000X, 363LA2200X, 207LP2900X
MO2013009799363L00000X
MO2004030088163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILMA5045004Medicare PIN
IL621825612Medicaid