Provider Demographics
NPI:1013599042
Name:KANSAS COGNITIVE CENTER
Entity Type:Organization
Organization Name:KANSAS COGNITIVE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:R
Authorized Official - Last Name:TEBOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-358-7257
Mailing Address - Street 1:250 N ROCK RD STE 170
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-2287
Mailing Address - Country:US
Mailing Address - Phone:316-358-7257
Mailing Address - Fax:316-358-7002
Practice Address - Street 1:250 N ROCK RD STE 170
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-2287
Practice Address - Country:US
Practice Address - Phone:316-358-7257
Practice Address - Fax:316-358-7002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSKA4607Medicaid