=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740541234
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSILYN RANAE HUMBLE M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2012
-----------------------------------------------------
Last Update Date | 06/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2711 S ROUSE ST STE B
-----------------------------------------------------
City | PITTSBURG
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66762-6621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-235-7612
-----------------------------------------------------
Fax | 620-235-7613
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2711 S ROUSE ST STE B
-----------------------------------------------------
City | PITTSBURG
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66762-6621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-235-7612
-----------------------------------------------------
Fax | 620-235-7613
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 04-38113
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------