Provider Demographics
NPI:1205131802
Name:OMOILE, JESSICAROSE NNEKA (MED, PLPC)
Entity type:Individual
Prefix:
First Name:JESSICAROSE
Middle Name:NNEKA
Last Name:OMOILE
Suffix:
Gender:F
Credentials:MED, PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 VENTNOR LN
Mailing Address - Street 2:
Mailing Address - City:RAYMORE
Mailing Address - State:MO
Mailing Address - Zip Code:64083-8385
Mailing Address - Country:US
Mailing Address - Phone:214-454-0403
Mailing Address - Fax:
Practice Address - Street 1:3100 MAIN ST
Practice Address - Street 2:SUITE 206
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-1931
Practice Address - Country:US
Practice Address - Phone:214-454-0403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-13
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010042212101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor