Provider Demographics
NPI:1912004342
Name:SAMPLE, JENNIFER A (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:A
Other - Last Name:LOWRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:201 ACADEMY ST
Mailing Address - Street 2:
Mailing Address - City:PLATTE CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64079-9653
Mailing Address - Country:US
Mailing Address - Phone:816-665-1080
Mailing Address - Fax:
Practice Address - Street 1:1104 PLATTE FALLS RD
Practice Address - Street 2:
Practice Address - City:PLATTE CITY
Practice Address - State:MO
Practice Address - Zip Code:64079-7629
Practice Address - Country:US
Practice Address - Phone:816-665-1080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1109812080T0002X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080T0002XAllopathic & Osteopathic PhysiciansPediatricsMedical Toxicology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204705701Medicaid
KS100347580AMedicaid
MO204705701Medicaid