Provider Demographics
NPI:1538131735
Name:HOLMES, JESSIE (MD)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:HOLMES
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 1:5525 W 119TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66209-3724
Mailing Address - Country:US
Mailing Address - Phone:913-491-4020
Mailing Address - Fax:913-491-4725
Practice Address - Street 1:5525 W 119TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66209-3724
Practice Address - Country:US
Practice Address - Phone:913-491-4020
Practice Address - Fax:913-491-4725
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS6427681174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100389380AMedicaid
KS100389380AMedicaid
KS6738074Medicare ID - Type Unspecified