Provider Demographics
NPI:1336250232
Name:POWELL, JENNIFER S (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:S
Last Name:POWELL
Suffix:
Gender:F
Credentials:MD
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 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:120 HOSPITAL DR
Practice Address - Street 2:SUITE 100
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-9238
Practice Address - Country:US
Practice Address - Phone:417-533-6751
Practice Address - Fax:417-533-6755
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006107611207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO# PENDINGMedicaid
MO# PENDINGMedicaid
MO# PENDINGMedicare ID - Type UnspecifiedMO MDCR PROVIDER #