1912963398 NPI number — JENNIFER G FUNKE PT

Table of content: JENNIFER G FUNKE PT (NPI 1912963398)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912963398 NPI number — JENNIFER G FUNKE PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FUNKE
Provider First Name:
JENNIFER
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

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

NPI Number Information

NPI Number:
1912963398
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1064
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POPLAR BLUFF
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63902-1064
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-778-9348
Provider Business Mailing Address Fax Number:
573-686-0178

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3381 KANELL BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POPLAR BLUFF
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63901-3060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-775-0761
Provider Business Practice Location Address Fax Number:
573-785-0031
Provider Enumeration Date:
04/25/2006

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: 225100000X , with the licence number:  2003022299 , 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: 486083702 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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