Provider Demographics
NPI:1609660554
Name:JESPERSON, NICHOLAS TANNER (DO)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:TANNER
Last Name:JESPERSON
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12680 OLIVE BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6322
Mailing Address - Country:US
Mailing Address - Phone:314-251-8888
Mailing Address - Fax:314-251-8889
Practice Address - Street 1:12680 OLIVE BLVD STE 300
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6322
Practice Address - Country:US
Practice Address - Phone:314-251-8888
Practice Address - Fax:314-251-8889
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program