Healthcare Provider Details

I. General information

NPI: 1245913359
Provider Name (Legal Business Name): JONATHAN EMMANUEL RUIZ LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2023
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 DR MARTIN LUTHER KING JR BLVD
KANSAS CITY MO
64130-2807
US

IV. Provider business mailing address

99 S 17TH ST
KANSAS CITY KS
66102-4946
US

V. Phone/Fax

Practice location:
  • Phone: 913-961-9962
  • Fax:
Mailing address:
  • Phone: 913-961-9962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2023031829
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2026019386
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number07254
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: