Provider Demographics
NPI:1568589398
Name:FUENTES, JO ELLEN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:JO
Middle Name:ELLEN
Last Name:FUENTES
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8610 STARK AVE
Mailing Address - Street 2:
Mailing Address - City:RAYTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:64138-3165
Mailing Address - Country:US
Mailing Address - Phone:816-529-7307
Mailing Address - Fax:
Practice Address - Street 1:15238 BROADMOOR ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66223-3137
Practice Address - Country:US
Practice Address - Phone:816-529-7307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSTHR-587174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist