Provider Demographics
NPI:1215374244
Name:ISHAM, JENNIFER (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:ISHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 CARONDELET DR STE 310
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64114-4801
Mailing Address - Country:US
Mailing Address - Phone:816-942-8692
Mailing Address - Fax:816-942-4830
Practice Address - Street 1:1004 CARONDELET DR STE 310
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-4801
Practice Address - Country:US
Practice Address - Phone:816-942-8692
Practice Address - Fax:816-942-4830
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016027887208000000X
KS0439314208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics