Healthcare Provider Details

I. General information

NPI: 1780491472
Provider Name (Legal Business Name): JONATHAN EMMONS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2024
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7001 N LOCUST ST # A117
GLADSTONE MO
64118-2531
US

IV. Provider business mailing address

7001 N LOCUST ST # A117
GLADSTONE MO
64118-2531
US

V. Phone/Fax

Practice location:
  • Phone: 816-226-8061
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2024047157
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: