Healthcare Provider Details

I. General information

NPI: 1104432806
Provider Name (Legal Business Name): JEFFERSON MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2020
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 E BROADWAY ST
BRUNSWICK MO
65236-1468
US

IV. Provider business mailing address

1502 N JEFFERSON ST
CARROLLTON MO
64633-1948
US

V. Phone/Fax

Practice location:
  • Phone: 660-542-1695
  • Fax:
Mailing address:
  • Phone: 660-542-1695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LESLEY DELANEY
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 660-542-1695