MEDICARE: JACQUELINE VONFELDT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	305R00000X	Preferred Provider Organization	2717	KS

General Provider Information

NPI Number	:	1588037345
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACQUELINE VONFELDT

Provider Business Mailing Address
First Line	:	515 N RIDGE RD
Second Line	:	200
City	:	WICHITA
State	:	KS
Zip	:	67212-6389
Country	:	US
Telephone Number	:	316-202-8292
Fax Number	:

Provider Business Practice Location Address
First Line	:	515 N RIDGE RD
Second Line	:	200
City	:	WICHITA
State	:	KS
Zip	:	67212-6389
Country	:	US
Telephone Number	:	316-202-8292
Fax Number	:

Authorized Official
Title or Position	:	MARRIAGE AND FAMILY THERAPIST
Name	:	JACQUELINE VONFELDT
Credential	:
Telephone Number	:	316-202-8292

Provider Enumeration Date	:	11/02/2015
Last Update Date	:	11/02/2015

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