Basic Information
| Provider Information | |||||||||
| NPI: | 1497944797 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | DAWN | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5501 NW 62ND TER | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641512408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165848884 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3901 RAINBOW BLVD | ||||||||
| Address2: | STE G600 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 661608500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135889600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2007 | ||||||||
| LastUpdateDate: | 03/10/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 46080 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 200587770A | 05 | KS | MEDICAID | 1497944797 | 05 | MO | MEDICAID |