Basic Information
| Provider Information | |||||||||
| NPI: | 1831678671 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENNINGS | ||||||||
| FirstName: | TAYLOR | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CLARK | ||||||||
| OtherFirstName: | TAYLOR | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 4046 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658084046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172695712 | ||||||||
| FaxNumber: | 4172697567 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 E PRIMROSE ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172699812 | ||||||||
| FaxNumber: | 4172699853 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2018 | ||||||||
| LastUpdateDate: | 11/15/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 2018026937 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.