Healthcare Provider Details

I. General information

NPI: 1891259875
Provider Name (Legal Business Name): JAYNE TEDDER DNP, AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2019
Last Update Date: 01/14/2022
Certification Date: 01/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9100 PARK ST STE 100
LENEXA KS
66215-3353
US

IV. Provider business mailing address

9100 PARK ST STE 100
LENEXA KS
66215-3353
US

V. Phone/Fax

Practice location:
  • Phone: 877-279-5960
  • Fax: 877-384-3106
Mailing address:
  • Phone: 877-279-5960
  • Fax: 877-384-3106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number53-80127-071
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number2021011085
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2013019630
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number14124413071
License Number StateKS
# 5
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2021011085
License Number StateMO
# 6
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number53-80127-071
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: