Basic Information
| Provider Information | |||||||||
| NPI: | 1386259117 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANNESS | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | RACHELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ATC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BECKETT | ||||||||
| OtherFirstName: | JORDAN | ||||||||
| OtherMiddleName: | RACHELLE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | ATC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 209 ESSEX DR | ||||||||
| Address2: | |||||||||
| City: | SMITHVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640898395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733307007 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 398 BLUE JAY DR | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640681977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164072315 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2020 | ||||||||
| LastUpdateDate: | 09/09/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 2016025471 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.