Healthcare Provider Details

I. General information

NPI: 1396293908
Provider Name (Legal Business Name): TARA JENKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARA MOORE RN

II. Dates (important events)

Enumeration Date: 09/13/2016
Last Update Date: 09/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 S 4TH ST
LEAVENWORTH KS
66048-5014
US

IV. Provider business mailing address

2619 N 123RD ST
KANSAS CITY KS
66109-3312
US

V. Phone/Fax

Practice location:
  • Phone: 913-682-2000
  • Fax:
Mailing address:
  • Phone: 913-909-3013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number116082
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: