Provider Demographics
NPI:1457073876
Name:KIBBE, JESSIE LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:LEE
Last Name:KIBBE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2432 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-2664
Mailing Address - Country:US
Mailing Address - Phone:573-755-2305
Mailing Address - Fax:
Practice Address - Street 1:2432 E MAIN ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755-2664
Practice Address - Country:US
Practice Address - Phone:573-755-2305
Practice Address - Fax:800-800-5123
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-13
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
TN5265363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant