Healthcare Provider Details

I. General information

NPI: 1336370162
Provider Name (Legal Business Name): JASON JIMMY SO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2009
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 IOWA BLVD
TRENTON MO
64683-8343
US

IV. Provider business mailing address

16324 CENTURY ST
OVERLAND PARK KS
66221-6942
US

V. Phone/Fax

Practice location:
  • Phone: 660-358-5700
  • Fax:
Mailing address:
  • Phone: 816-806-1369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2009011011
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: