1649434200 NPI number — DR. JESSICA RENEE KING MD

Table of content: DR. JESSICA RENEE KING MD (NPI 1649434200)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649434200 NPI number — DR. JESSICA RENEE KING MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KING
Provider First Name:
JESSICA
Provider Middle Name:
RENEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VAN BIBBER
Provider Other First Name:
JESSICA
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1649434200
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1905 W 19TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNTAIN GROVE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65711-1287
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-926-1770
Provider Business Mailing Address Fax Number:
417-926-1785

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1905 W 19TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNTAIN GROVE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65711-1287
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-926-1770
Provider Business Practice Location Address Fax Number:
417-926-1785
Provider Enumeration Date:
07/14/2008

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: 207Q00000X , with the licence number:  2008017836 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 2009020461 , 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: 26D2006074 . This is a "CLIA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 504114802 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 26D0889777 . This is a "CLIA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 1649434200 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 594438806 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 507780302 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 204253207 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 597780303 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01296849 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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