Provider Demographics
NPI:1639106560
Name:THEIS, JENNIFER K (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:K
Last Name:THEIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:K
Other - Last Name:STRATTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803
Mailing Address - Country:US
Mailing Address - Phone:417-347-4662
Mailing Address - Fax:
Practice Address - Street 1:3401 MCINTOSH CIR STE 100
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3651
Practice Address - Country:US
Practice Address - Phone:417-347-7200
Practice Address - Fax:417-347-7236
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO142538363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100091520AMedicaid
MO148311OtherANTHEM
MO425136306Medicaid
500014242OtherRR MEDICARE
KS100380720AMedicaid
KS100380720AMedicaid
MO425136306Medicaid