Basic Information
| Provider Information | |||||||||
| NPI: | 1679736235 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | JILLIAN | ||||||||
| MiddleName: | MOORE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOORE | ||||||||
| OtherFirstName: | JILLIAN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 19550 E 39TH ST S | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | INDEPENDENCE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640572303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164789071 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 19550 E 39TH ST S | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | INDEPENDENCE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640572303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164789071 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2008 | ||||||||
| LastUpdateDate: | 03/12/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN162789 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 131756716A | 05 | GA | MEDICAID |