Healthcare Provider Details

I. General information

NPI: 1871127126
Provider Name (Legal Business Name): JENNIFER HE DIEBOLT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2020
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2521 GLENN HENDREN DR STE 104
LIBERTY MO
64068-3388
US

IV. Provider business mailing address

2521 GLENN HENDREN DR STE 104
LIBERTY MO
64068-3388
US

V. Phone/Fax

Practice location:
  • Phone: 816-781-1001
  • Fax: 816-792-0408
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number04-53982
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number2026029566
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: