Provider Demographics
NPI:1003903550
Name:MALOSSI, JENNIFER A (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:MALOSSI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-9007
Mailing Address - Country:US
Mailing Address - Phone:417-875-3000
Mailing Address - Fax:
Practice Address - Street 1:1001 E PRIMROSE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5155
Practice Address - Country:US
Practice Address - Phone:417-875-3381
Practice Address - Fax:417-875-3690
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228628-1208800000X
MO2017017909208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1003903550Medicaid
MO200044423Medicaid