1013447903 NPI number — JEMMALEE ANDIE ANDERSON BSSW MARS

Table of content: JEMMALEE ANDIE ANDERSON BSSW MARS (NPI 1013447903)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013447903 NPI number — JEMMALEE ANDIE ANDERSON BSSW MARS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
JEMMALEE
Provider Middle Name:
ANDIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BSSW MARS
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:
1013447903
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
925 HIGHWAY V V
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENNETT
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63857-0071
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-888-6454
Provider Business Mailing Address Fax Number:
573-888-2369

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1109 JONES ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENNETT
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63857-3824
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-888-5925
Provider Business Practice Location Address Fax Number:
573-888-2369
Provider Enumeration Date:
06/14/2017

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: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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