Healthcare Provider Details

I. General information

NPI: 1750770582
Provider Name (Legal Business Name): MEREDITH JOANN JENKINS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2015
Last Update Date: 07/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3302 MCINTOSH CIR STE 1
JOPLIN MO
64804-3648
US

IV. Provider business mailing address

PO BOX 3810
JOPLIN MO
64803-3810
US

V. Phone/Fax

Practice location:
  • Phone: 417-347-7272
  • Fax: 417-347-7915
Mailing address:
  • Phone: 417-347-7272
  • Fax: 417-347-7915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2019014624
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2463
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: