Healthcare Provider Details

I. General information

NPI: 1972813764
Provider Name (Legal Business Name): JAMY DEAN VANSYCKLE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2010
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 BROADWAY BLVD
KANSAS CITY MO
64111-2659
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 816-302-3700
  • Fax: 816-302-9939
Mailing address:
  • Phone: 816-234-3000
  • Fax: 816-302-9939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2010011399
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: