Healthcare Provider Details

I. General information

NPI: 1033832522
Provider Name (Legal Business Name): JESSICA DEWITT ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2022
Last Update Date: 09/21/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 NE SAINT LUKES BLVD
LEES SUMMIT MO
64086-6000
US

IV. Provider business mailing address

4007 E 115TH ST
KANSAS CITY MO
64137-2301
US

V. Phone/Fax

Practice location:
  • Phone: 816-246-4302
  • Fax:
Mailing address:
  • Phone: 785-766-3764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: