Healthcare Provider Details

I. General information

NPI: 1073554820
Provider Name (Legal Business Name): JACKIE WAYNE TENNEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 PROSPECT AVE SUITE 646
KANSAS CITY MO
64132-1100
US

IV. Provider business mailing address

6501 E 87TH ST
KANSAS CITY MO
64138-2732
US

V. Phone/Fax

Practice location:
  • Phone: 816-444-8400
  • Fax: 816-444-8407
Mailing address:
  • Phone: 816-444-8400
  • Fax: 816-444-8407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR7F09
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: