Healthcare Provider Details

I. General information

NPI: 1275896326
Provider Name (Legal Business Name): KELLEY RAY JENKINS BC-FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2012
Last Update Date: 06/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 E WALNUT LAWN SUITE 201
SPRINGFIELD MO
65807
US

IV. Provider business mailing address

960 E WALNUT LAWN SUITE 201
SPRINGFIELD MO
65807
US

V. Phone/Fax

Practice location:
  • Phone: 417-269-4450
  • Fax: 417-269-8333
Mailing address:
  • Phone: 417-269-4450
  • Fax: 417-269-8333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2006023820
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: