Provider Demographics
NPI:1245283951
Name:EBERSOLE, JENNIFER DAWN (ARNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DAWN
Last Name:EBERSOLE
Suffix:
Gender:
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 W LA MESA DR
Mailing Address - Street 2:
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801-2838
Mailing Address - Country:US
Mailing Address - Phone:620-225-6821
Mailing Address - Fax:
Practice Address - Street 1:305 W 15TH ST STE 103
Practice Address - Street 2:
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901-2455
Practice Address - Country:US
Practice Address - Phone:620-236-3125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-45719-111363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS171814Medicare PIN
KS171815Medicare PIN
KS171813Medicare PIN
KS171810Medicare PIN