Provider Demographics
NPI:1295283067
Name:BARTON, JACOB M (NP)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:M
Last Name:BARTON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 E EVERGREEN ST
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:MO
Mailing Address - Zip Code:64429-2400
Mailing Address - Country:US
Mailing Address - Phone:816-632-2101
Mailing Address - Fax:816-649-3383
Practice Address - Street 1:1600 E EVERGREEN ST
Practice Address - Street 2:MP II STE C
Practice Address - City:CAMERON
Practice Address - State:MO
Practice Address - Zip Code:64429-2400
Practice Address - Country:US
Practice Address - Phone:816-632-2139
Practice Address - Fax:816-632-2315
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016044505363L00000X
MO2011003589163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1295283067Medicaid