Individual
JENNIFER A SAMPLE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
1104 PLATTE FALLS RD, PLATTE CITY, MO 64079-7629
(816) 665-1080
Mailing address
201 ACADEMY ST, PLATTE CITY, MO 64079-9653
(816) 665-1080
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
110981
MO
2080T0002X
Pediatric Medical Toxicology Physician
110981
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100347580A
—
KS
05
—
204705701
—
MO
Enumeration date
09/20/2006
Last updated
12/13/2019
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