Provider Demographics
NPI:1174856736
Name:POWELL, JESSICA ELIZABETH (APRN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELIZABETH
Last Name:POWELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 N MERIDIAN RD
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-5103
Mailing Address - Country:US
Mailing Address - Phone:316-587-5337
Mailing Address - Fax:866-659-1837
Practice Address - Street 1:305 N MERIDIAN RD
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:KS
Practice Address - Zip Code:67114-5103
Practice Address - Country:US
Practice Address - Phone:316-587-5337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-15
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-75032-011363LA2200X
KSPENDING363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200734460DMedicaid