1710192588 NPI number — MS. JENNIFER OLSEN POLNIAK R.D., C.D.E, PA-C

Table of content: MS. JENNIFER OLSEN POLNIAK R.D., C.D.E, PA-C (NPI 1710192588)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710192588 NPI number — MS. JENNIFER OLSEN POLNIAK R.D., C.D.E, PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLNIAK
Provider First Name:
JENNIFER
Provider Middle Name:
OLSEN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
R.D., C.D.E, PA-C
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:
1710192588
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/01/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 843966
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KANSAS CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64184-3966
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-884-3300
Provider Business Mailing Address Fax Number:
573-884-0943

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
303 N KEENE ST STE 301
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65201-8053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-882-8000
Provider Business Practice Location Address Fax Number:
573-882-6600
Provider Enumeration Date:
05/14/2007

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: 133V00000X , with the licence number:  0221025253 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 2016024375 , 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: 09720278 . This is a "DIABETES EDUCATOR CERTIFI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 220039284 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2001025253 . This is a "STATE LICENSE DIETITIAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".