Healthcare Provider Details

I. General information

NPI: 1073448106
Provider Name (Legal Business Name): JACOB MICHAEL PRESTIDGE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9393 W 110TH ST STE 532
OVERLAND PARK KS
66210-1442
US

IV. Provider business mailing address

7020 WALMER ST
OVERLAND PARK KS
66204-1437
US

V. Phone/Fax

Practice location:
  • Phone: 816-875-0072
  • Fax:
Mailing address:
  • Phone: 816-506-8098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT03819T
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: