Healthcare Provider Details

I. General information

NPI: 1194277020
Provider Name (Legal Business Name): JACKIE BOUNDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACKIE ROBERTS

II. Dates (important events)

Enumeration Date: 10/26/2016
Last Update Date: 10/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 S HUDSON ST
BUCKNER MO
64016-8142
US

IV. Provider business mailing address

825 S BUSINESS HIGHWAY 13
LEXINGTON MO
64067-1515
US

V. Phone/Fax

Practice location:
  • Phone: 877-344-3572
  • Fax: 660-251-0524
Mailing address:
  • Phone: 660-259-2440
  • Fax: 660-251-0524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2016029134
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: