Healthcare Provider Details

I. General information

NPI: 1912004342
Provider Name (Legal Business Name): JENNIFER A SAMPLE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER A LOWRY MD

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 12/13/2019
Certification Date: 12/13/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1104 PLATTE FALLS RD
PLATTE CITY MO
64079-7629
US

IV. Provider business mailing address

201 ACADEMY ST
PLATTE CITY MO
64079-9653
US

V. Phone/Fax

Practice location:
  • Phone: 816-665-1080
  • Fax:
Mailing address:
  • Phone: 816-665-1080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number110981
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2080T0002X
TaxonomyPediatric Medical Toxicology Physician
License Number110981
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: