1043319957 NPI number — FAMILY MEDICINE OF JEFFERSON CITY, LLC

Table of content: EMMA JANE TECCA LCSW (NPI 1770299042)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043319957 NPI number — FAMILY MEDICINE OF JEFFERSON CITY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY MEDICINE OF JEFFERSON CITY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1043319957
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1616 SOUTHRIDGE DR
Provider Second Line Business Mailing Address:
SUITE #203
Provider Business Mailing Address City Name:
JEFFERSON CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65109-5677
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-659-7300
Provider Business Mailing Address Fax Number:
573-636-0555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1616 SOUTHRIDGE DR
Provider Second Line Business Practice Location Address:
SUITE #203
Provider Business Practice Location Address City Name:
JEFFERSON CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65109-5677
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-659-7300
Provider Business Practice Location Address Fax Number:
573-636-0555
Provider Enumeration Date:
09/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LAVERY
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
P
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
573-659-7300

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  R9J28 , 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)





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