Healthcare Provider Details

I. General information

NPI: 1497446900
Provider Name (Legal Business Name): MR. FLOYD LEVI JERNIGAN III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2023
Last Update Date: 05/16/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 S NATIONAL AVE # PROF160
SPRINGFIELD MO
65897-0001
US

IV. Provider business mailing address

506 WINCHESTER DR
ROLLA MO
65401-3831
US

V. Phone/Fax

Practice location:
  • Phone: 417-836-5000
  • Fax:
Mailing address:
  • Phone: 573-647-1631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: