1306972336 NPI number — JACINDA ELAINE DOUGHERTY PSYD

Table of content: JACINDA ELAINE DOUGHERTY PSYD (NPI 1306972336)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306972336 NPI number — JACINDA ELAINE DOUGHERTY PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOUGHERTY
Provider First Name:
JACINDA
Provider Middle Name:
ELAINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TRAUTWEIN
Provider Other First Name:
JACIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1306972336
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3757 S. GREYSTONE CT.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65804-0000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-877-7500
Provider Business Mailing Address Fax Number:
417-877-7600

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3757 S. GREYSTONE CT.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65804-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-877-7500
Provider Business Practice Location Address Fax Number:
417-877-7600
Provider Enumeration Date:
02/26/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  2001031418 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 152184 . This is a "BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 495693707 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".