1730457300 NPI number — MRS. JACINDA REA LCSW

Table of content: MRS. JACINDA REA LCSW (NPI 1730457300)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730457300 NPI number — MRS. JACINDA REA LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REA
Provider First Name:
JACINDA
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
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:
1730457300
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/07/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
406 E 3RD TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAMAR
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64759-1150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-214-6648
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
203 2ND AVE SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74354-6818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-214-6648
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/09/2011

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: 1041C0700X , with the licence number:  2016029485 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 5174 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: D27240 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 1280287 . This is a "MO CARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 002628535 . This is a "CTS CHILDRENS TREATMENT SERVICES" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 1730457300 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4277661 . This is a "AETNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 601117207 . This is a "MAGELLAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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