Provider Demographics
NPI:1851119911
Name:WOODARD, JESIKA
Entity type:Individual
Prefix:
First Name:JESIKA
Middle Name:
Last Name:WOODARD
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 1:5149 CHELTENHAM RD
Mailing Address - Street 2:
Mailing Address - City:BLACK JACK
Mailing Address - State:MO
Mailing Address - Zip Code:63033-7424
Mailing Address - Country:US
Mailing Address - Phone:314-386-4644
Mailing Address - Fax:
Practice Address - Street 1:14733 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-2660
Practice Address - Country:US
Practice Address - Phone:314-339-7732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024039220103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst