Healthcare Provider Details

I. General information

NPI: 1386259117
Provider Name (Legal Business Name): JORDAN RACHELLE VANNESS ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JORDAN RACHELLE BECKETT ATC

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

398 BLUE JAY DR
LIBERTY MO
64068-1977
US

IV. Provider business mailing address

209 ESSEX DR
SMITHVILLE MO
64089-8395
US

V. Phone/Fax

Practice location:
  • Phone: 816-407-2315
  • Fax:
Mailing address:
  • Phone: 573-330-7007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2016025471
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: