Healthcare Provider Details

I. General information

NPI: 1932318367
Provider Name (Legal Business Name): JENNIFER ACOSTA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 10/19/2023
Certification Date: 10/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4818 S TUJUNGA DR
SPRINGFIELD MO
65810-1125
US

IV. Provider business mailing address

4818 S TUJUNGA DR
SPRINGFIELD MO
65810-1125
US

V. Phone/Fax

Practice location:
  • Phone: 785-250-7910
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2016023555
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: