MEDICARE: JACKSON KLUMP STUDENT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	94-12680	KS

General Provider Information

NPI Number	:	1942083811
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKSON KLUMP STUDENT

Provider Business Mailing Address
First Line	:	3901 RAINBOW BLVD # MS 2027
Second Line	:
City	:	KANSAS CITY
State	:	KS
Zip	:	66160-8500
Country	:	US
Telephone Number	:	913-588-1227
Fax Number	:

Provider Business Practice Location Address
First Line	:	3901 RAINBOW BLVD # MS 2027
Second Line	:
City	:	KANSAS CITY
State	:	KS
Zip	:	66160-8500
Country	:	US
Telephone Number	:	913-588-1227
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/15/2023
Last Update Date	:	06/15/2026

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Directions to “ JACKSON KLUMP STUDENT” Practice Location

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