Basic Information
| Provider Information | |||||||||
| NPI: | 1437212594 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PROCTOR | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 411851 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641411851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135886701 | ||||||||
| FaxNumber: | 9135886677 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901 RAINBOW BLVD MSC 3010 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 661600001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135886719 | ||||||||
| FaxNumber: | 9135884676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 10/22/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 15-00984 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 200266580A | 05 | KS | MEDICAID |