Provider Demographics
NPI:1720492028
Name:JEFFERSON, STACY ANTOINETTE (MD)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:ANTOINETTE
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 419052
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-9052
Mailing Address - Country:US
Mailing Address - Phone:314-851-1000
Mailing Address - Fax:
Practice Address - Street 1:1475 KISKER RD STE 230
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63304-8791
Practice Address - Country:US
Practice Address - Phone:636-939-5000
Practice Address - Fax:636-939-5002
Is Sole Proprietor?:No
Enumeration Date:2014-06-13
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017018156207Q00000X, 207Q00000X
IL125065259390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program