Provider Demographics
NPI:1073554820
Name:TENNEY, JACKIE WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:WAYNE
Last Name:TENNEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6501 E 87TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64138-2732
Mailing Address - Country:US
Mailing Address - Phone:816-444-8400
Mailing Address - Fax:816-444-8407
Practice Address - Street 1:6400 PROSPECT AVE
Practice Address - Street 2:SUITE 646
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64132-1100
Practice Address - Country:US
Practice Address - Phone:816-444-8400
Practice Address - Fax:816-444-8407
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7F09208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics