Healthcare Provider Details

I. General information

NPI: 1689635864
Provider Name (Legal Business Name): MARY V CHANCE APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY V JENKINS

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 03/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S 169 HWY
SMITHVILLE MO
64089-9317
US

IV. Provider business mailing address

969 NORTHWYCK DR
LIBERTY MO
64068-3354
US

V. Phone/Fax

Practice location:
  • Phone: 816-461-8288
  • Fax: 816-461-6586
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number104029
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: