Provider Demographics
NPI:1083712327
Name:FLYNN, JODI (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JODI
Middle Name:
Last Name:FLYNN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 E WALNUT LAWN ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-7506
Mailing Address - Country:US
Mailing Address - Phone:417-269-8142
Mailing Address - Fax:417-269-8260
Practice Address - Street 1:960 E WALNUT LAWN ST
Practice Address - Street 2:SUITE 203
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7506
Practice Address - Country:US
Practice Address - Phone:417-269-8142
Practice Address - Fax:417-269-8260
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003002309363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP82212Medicare UPIN
MO97249Medicare ID - Type Unspecified