Provider Demographics
NPI:1851963888
Name:GROTE, JORDAN RENEE (FNP-C, FNP-BC)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:RENEE
Last Name:GROTE
Suffix:
Gender:F
Credentials:FNP-C, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 802843
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-2843
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2115 S FREMONT AVE STE 3300
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2246
Practice Address - Country:US
Practice Address - Phone:417-820-5206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-09
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021025329363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420099845Medicaid