Healthcare Provider Details

I. General information

NPI: 1063685931
Provider Name (Legal Business Name): JENNIFER LEE NEITZEL D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2008
Last Update Date: 04/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 NE 96TH STREET
LIBERTY MO
64068
US

IV. Provider business mailing address

9405 N OAK TRFWY
KANSAS CITY MO
64155
US

V. Phone/Fax

Practice location:
  • Phone: 816-412-2900
  • Fax: 816-412-2915
Mailing address:
  • Phone: 918-232-2487
  • Fax: 816-792-3245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2009004531
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: