1801972682 NPI number — JAMA JELAINE BOGART FNP

Table of content: JAMA JELAINE BOGART FNP (NPI 1801972682)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801972682 NPI number — JAMA JELAINE BOGART FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOGART
Provider First Name:
JAMA
Provider Middle Name:
JELAINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FOSSETT
Provider Other First Name:
JAMA
Provider Other Middle Name:
JELAINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP-C, DNP, PMHNP-BC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1801972682
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 S ASH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEVADA
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64772-3223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-448-3600
Provider Business Mailing Address Fax Number:
417-448-3796

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
345 S BARRETT LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEVADA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64772-4255
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-448-2439
Provider Business Practice Location Address Fax Number:
417-549-6112
Provider Enumeration Date:
10/27/2006

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: 363LP0808X , with the licence number:  2021050610 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 106090 , 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: 1801972682 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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