Healthcare Provider Details

I. General information

NPI: 1831483882
Provider Name (Legal Business Name): MOLLI JACKSON ITTEL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MOLLI JACKSON BOYD

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 GILLHAM RD
KANSAS CITY MO
64108-4619
US

IV. Provider business mailing address

2401 GILLHAM RD PROVIDER ENROLLMENT DEPT
KANSAS CITY MO
64108-4619
US

V. Phone/Fax

Practice location:
  • Phone: 816-234-3000
  • Fax: 816-302-9939
Mailing address:
  • Phone: 816-701-5200
  • Fax: 816-302-9939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2015008262
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.127109
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number04-37834
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: