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General NPI Number Information
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NPI Number | 1104432806
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Entity Type | Organization
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Legal Business Name | JEFFERSON MEDICAL GROUP
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Dates
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Enumeration Date | 09/17/2020
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Last Update Date | 05/12/2025
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Provider Practice Location Address
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Address Line | 807 E BROADWAY ST
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City | BRUNSWICK
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State | MO
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Zip | 65236-1468
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Country | US
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Telephone | 660-542-1695
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Fax |
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Provider Business Mailing Address
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Address Line | 1502 N JEFFERSON ST
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City | CARROLLTON
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State | MO
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Zip | 64633-1948
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Country | US
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Telephone | 660-542-1695
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Fax |
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Authorized Official
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Title or Position | CHIEF FINANCIAL OFFICER
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Name | LESLEY DELANEY
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Credential |
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Telephone | 660-542-1695
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State |
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