Provider Demographics
NPI:1558660688
Name:JESPERSEN, CAROL ELAINE (RN)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ELAINE
Last Name:JESPERSEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:PAOLA
Mailing Address - State:KS
Mailing Address - Zip Code:66071-1115
Mailing Address - Country:US
Mailing Address - Phone:785-979-7002
Mailing Address - Fax:
Practice Address - Street 1:4911 STATE AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66102-1749
Practice Address - Country:US
Practice Address - Phone:913-287-8851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-15
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13-100453-122163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100211880CMedicaid
KS100211880DMedicaid