Provider Demographics
NPI:1710082078
Name:PFEIFER, JACQUELINE ROSE (PHD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ROSE
Last Name:PFEIFER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18955 WEST 116TH ST
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66061
Mailing Address - Country:US
Mailing Address - Phone:913-888-2362
Mailing Address - Fax:
Practice Address - Street 1:3515 S 4TH ST
Practice Address - Street 2:PROFESSIONAL ASSOCIATION
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048
Practice Address - Country:US
Practice Address - Phone:913-651-8415
Practice Address - Fax:913-772-8580
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS866103T00000X
MOR0407103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS060779OtherBLUE CROSS BLUE SHIELD
KS004517OtherBLUE CROSS BLUE SHIELD GR
22447022OtherKANSAS CITY BLUE CROSS BL
1049473OtherCIGNA
7154171OtherAETNA
KS060779OtherBLUE CROSS BLUE SHIELD
1049473OtherCIGNA
22447022OtherKANSAS CITY BLUE CROSS BL