Provider Demographics
NPI:1043215601
Name:WATTENBARGER, JENNIFER RACHEL (NP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:RACHEL
Last Name:WATTENBARGER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:RACHEL
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2340 E MEYER BLVD BLDG 2
Mailing Address - Street 2:SUITE 546
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64132-1105
Mailing Address - Country:US
Mailing Address - Phone:816-926-0777
Mailing Address - Fax:816-926-0707
Practice Address - Street 1:2340 E MEYER BLVD STE 546
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64132-1110
Practice Address - Country:US
Practice Address - Phone:816-926-0777
Practice Address - Fax:816-926-0707
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO149378363L00000X
OK97914363L00000X
KS45306363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS4287510101Medicare UPIN
MO425784410Medicare UPIN
KS590B671AMedicare ID - Type Unspecified
MO590B671Medicare ID - Type Unspecified