Provider Demographics
NPI:1437212594
Name:PROCTOR, JENNIFER S (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:S
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 411851
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64141-1851
Mailing Address - Country:US
Mailing Address - Phone:913-588-6701
Mailing Address - Fax:913-588-6677
Practice Address - Street 1:3901 RAINBOW BLVD MSC 3010
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160-0001
Practice Address - Country:US
Practice Address - Phone:913-588-6719
Practice Address - Fax:913-588-4676
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2015-10-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KS15-00984363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200266580AMedicaid
KS200266580AMedicaid